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

Transcription

1 ALBERTA CHILDREN S HOSPITAL PEDIATRIC TRAUMA PROGRAM ANNUAL REPORT 2016 ACH Trauma Program Staff Dr. Jonathan Guilfoyle... Medical Director Dr. Steve Lopushinsky... In-Patient Surgical Lead Sharleen Luzny / Jennifer Tweed (March)... 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 ACH Trauma Program has enjoyed another productive and successful year as we continue to strive for excellence across the entire spectrum of trauma care. We are prepared for our upcoming re-accreditation through Accreditation Canada and welcome this opportunity to ensure that we continue to deliver the highest level of care to the children of Southern Alberta. We would like to start by thanking Dr. Jim Kellner and the Department of Pediatrics for granting us an operational budget. In previous years, the program has relied on generous donations from the Alberta Children s Hospital Foundation, but did not have a secure, sustainable source of funding. This budget will help to subsidize the many educational endeavors of our program. Our Trauma Program s emphasis on prevention, education, and coordinated, collaborative, evidence-based, multi-disciplinary care are fundamental to our success in providing the highest level of care. The first step in trauma care is injury prevention. Our program is a vocal advocate for injury prevention and we are fortunate to have partners at both the provincial and national level. Through both our own database and through the Canadian Hospital Injury Reporting Prevention Program (CHIRPP), we are able to monitor injury trends and target areas of intervention. One such intervention stemmed from the recognition of the frequency of falls from second-storey windows, particularly in the summer months. The ACH Trauma Program has partnered with the City of Calgary to bring forward an amendment to the National Building Code to restrict the opening of windows in an effort to prevent such injuries. Other initiatives include educational efforts to highlight the risk of ATV use in children as well as petitioning the provincial government to legislate stricter regulations for their use in minors. We are also collaborating on a national effort to collect further data on the nature of ATV injuries in children. Education has always been one of the great strengths of this Trauma Program, which we continue to build upon. The ACH Trauma Program continues to provide educational leadership for both ACH clinical staff, as well as outreach education to rural and regional providers. On-going education provided by the Pediatric Trauma Program includes: mock/just-intime 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 the KidSIM program at ACH. We run regular mock trauma codes that involve the entire trauma team, beginning in the trauma bay and continuing to the OR. One of the big learning points highlighted was the need for the emergency trauma team and TTL to accompany an unstable patient up to the OR and to continue leading the resuscitation while the surgical and anesthesiology team prep the room and focus on the surgery at hand. 3

4 Another educational initiative recently developed is the monthly simulation program specifically for Emergency Physician Attendings. This program has been developed to help our physicians maintain competency in critical resuscitation skills that they may only infrequently use in their day-to-day clinical practice. The simulations occur in our trauma bay and include a full complement of nurses and an RRT to enhance the realism of the scenario. This has been coupled with a new ACH Pediatric Airway Course that most of the physician group has completed. In addition, a concerted effort has been made to teach bedside ultrasound skills to our physician group and we expect that most will have their formal ultrasound certification complete within the next year. The Brain Injury and Rehabilitation Program continues to provide services for patients who have suffered traumatic brain injuries. This program includes in-patient comprehensive rehabilitation services, as well as outpatient services in coordination with Gordon Townsend School. Curious About Concussion? is a clinical education session for patients and families that has been available for patients with mild traumatic brain injury for the past three years. The multidisciplinary team of nurses, physicians, respiratory therapists, and other frontline staff remain devoted to the care of these children and their families. This collaborative team is exceptional and the backbone of our success. The ACH Trauma Program would like to extend a heartfelt thank you to our amazing Emergency Medical Services team. They provide exceptional care, with limited resources, in the most austere environments and we are greatly appreciative of the work they do and the lives they save. We are in regular communication with EMS and they frequently attend our various meetings, so that together we can optimize the prehospital care of pediatric patients. Our rural partners do an excellent job of providing high-level care despite the broad geography of Southern Alberta and the disparate allocation of resources that can pose significant logistical challenges. The Trauma Program works closely with both the ACH Transport Team and Shock Trauma Air Rescue Society (STARS) to ensure the timely transport of these critically injured patients to ACH where they can receive definitive care. We are also in close contact with our rural partners, providing both feedback and educational outreach. Upon arrival to ACH, trauma patients are met by a world class, multi-disciplinary trauma team. The Trauma Program has developed and refined a trauma activation system that ensures that this team is assembled and ready promptly. The Trauma Team Leader (TTL) is a designated Emergency Physician currently on shift whose first priority is to manage resuscitations in the Trauma Bay. The Trauma Surgery Team responds to all trauma activations and co-manages the patient alongside the TTL, then assuming responsibility for the in-patient management of these children. The Pediatric Intensive Care Team also responds to all activations providing their expertise in the management 4

5 of critically ill patients and providing on-going care for those patients requiring intensive care. In addition to a Trauma Team Activation, we have also developed an OR Activation system which immediately mobilizes the OR Team and the on-call anesthesiologist for patients with airway emergencies or those that require an immediate operation. A child with multi-system injuries may also require the services of multiple other surgical subspecialties. We enjoy a great working relationship with our radiology department who also respond to all trauma activations, providing timely access to diagnostic imaging around the clock. The radiology department has committed to providing attending reads of all trauma activations within the hour in order to ensure accuracy and minimize discrepancies between preliminary and final reports. They have also committed to providing interventional radiology support 24/7. We are most fortunate to have such an incredible group of trauma nurses in our emergency department who are invaluable to our team. Nurses have the opportunity to maintain their skill set through the Trauma Nursing Core Course (TNCC) that is provided bi-annually, as well as a wide range of simulation programs with which our nurses are integrally involved. We also have an exceptional respiratory therapy team that respond to all activations. As one can well imagine, the coordination of all of these disciplines for a critically injured child with competing medical issues is essential to provide the highest level of care. The ACH Trauma Program continually endeavors to bridge gaps and to optimize seamless care for these patients. We have broad subspecialty representation at our monthly Trauma Committee meetings which provides a forum to share concerns and make recommendations to further optimize our system. Our mock codes serve to further foster the close working relationship and teamwork among the various specialties caring for these patients. The In-patient Trauma Program provides integrated care for patients and families, from time of first assessment through hospital discharge. They are supported by multiple surgical subspecialties, including but not limited to pediatric general surgery, orthopedic surgery, neurosurgery, plastic surgery, and urology. In-patient pediatrics and rehabilitation medicine are instrumental in long-term return to function and getting kids home as quickly as possible. Obviously the care of children with multi-system injuries is complex but is supported by a dedicated group of healthcare professionals including nursing, physical therapy, and social work. 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). We are very proud of our Trauma Coordinator Ms. Sherry MacGillivray who was recently elected to the TAC Board of Directors. 5

6 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. Dr. Jonathan 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 tireless dedication and commitment to our Pediatric Trauma Program. Trauma Committee Members 2016: Dr. Jonathan Guilfoyle (chair) Dr. Steve Lopushinsky / Dr. Natalie Yanchar (surgery lead) Dr. Andrea Boone (emergency lead) Dr. Eli Gilad (PICU) Dr. Ruth Connors / Dr. Nancy Ghazar / Dr. Jeremy Luntley / Dr. Jamin Mulvey (anesthesiology) Dr. Cathy Chrusch / Dr. Vijay Moorjani (diagnostic imagining) Dr. Clare Gallagher (neurosurgery) Dr. Fabio Ferri de Barros (orthopedics) Emma Folz / Wendy Bissett (PICU) Lisette Lockyer (trauma NP) Jessica Graham / Laura Slipp (OR) Sharleen Luzny / Jennifer Tweed / Suzanne Wickware (emergency) Colleen Belanger (in-patient trauma unit) Kathy Lyons (social work) Valerie Cook / Nora Ansah (injury prevention) Sherry MacGillivray (trauma coordinator) 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. 6

7 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. 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. 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. We were pleased when Dr. Natalie Yanchar joined this group in iii) Trauma Tertiary Survey The Pediatric Trauma Tertiary Survey is to be completed by the in-patient 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 2016 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 inhouse and can assist with a difficult airway. Activations are monitored and reviewed by the Trauma Committee. 7

8 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 2016 completion rate was 83%. viii) Provincial Nursing Trauma Resuscitation Record As a directive from the Provincial Trauma Committee, in 2012 the Alberta Trauma Coordinators 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 2014 after feedback from the end users. 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. This protocol was revised in 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 PICU 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 continual generous grants from the Alberta Children s Hospital Foundation, the Trauma Beading Program for major trauma patients remains on-going since 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 success. We would like to extend our gratitude to the ACH Child Life Specialists for making this important program a continued success. 8

9 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 - Members 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 9

10 3. Education i) Trauma Rounds Rounds are held in the ACH Ampitheatre to accommodate telehealth to outside centres January 21, 2016 Dr. Eli Gilad Resuscitation Fluids: What s New? February 25, 2016 Dr. Steve Lopushinsky Blunt Thoracic Trauma in Kids March 31, 2016 Dr. Vithya Gnanakumar Brain Injury Case Reviews: Rehabilitation Medicine Issues April 21, 2016 Dr. Diana Murray Checklists in Medicine: Are They in Need of a Reality Check? May 26, 2016 Dr. Khalid Fawaz Pediatric Thoracic and Lumbar Spine Injuries June 23, 2016 Dr. Ibtisam Al Shuaili Pediatric Chest Trauma September 22, 2016 Dr. Jeremy Luntley Lessons Learned from Mock Traumas October 27, 2016 Dr. Clare Gallagher ICP Emergencies November 24, 2016 Dr. Karen Barlow & Tina Samuel Head First! ED Concussion Management Update ii) iii) iv) 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 Simulation These mocks provide physicians, fellows, residents, nurses, respiratory therapists, nursing aides and unit clerks with an opportunity to learn from simulated trauma cases. At least once per year, one of these mocks start in the ED with a full activation of both Code 77 & 88 moving up to the OR to involved the entire OR team as well as General Surgery and other surgical services (ie: ENT). Outreach Education The partnership between the ACH Trauma Program and KidSIM, the Pediatric Human Patient Simulation Program, continues to deliver 10

11 education to both regional and rural partners. These are very popular multidisciplinary educational sessions that include pre-hospital as well as in hospital care givers. The following centres were visited in 2016: February March April May June September October November December Vulcan, Medicine Hat Didsbury, Strathmore Cardston, Fort McLeod, Black Diamond High River, Olds Cranbrook BC Red Deer, Brooks Lethbridge, Claresholm Banff, Canmore Crowsnest Pass, Pincher Creek v) Emergency Department 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. In 2015 the ED staff attending physicians joined this program for in-situ scenarios in the ED trauma room with the entire ED trauma team. 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 the rotating nursing support team. 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 2016) Pediatric Trauma Motorized Recreational Vehicles Sherry MacGillivray ix) Pediatric Emergencies Alberta Children s Hospital (PEACH) Annual Conference (Calgary, AB March 2016) Trauma Track Leads Sherry MacGillivray & Dr. Jonathan Guilfoyle 11

12 x) Pediatric Care Update (Calgary, AB April 2016) Pediatric Trauma Motorized Recreational Vehicles Sherry MacGillivray xi) Peri-Anesthesia Nurses of Alberta (Calgary, AB April 2016) Pediatric Trauma Motorized Recreational Vehicles Sherry MacGillivray xii) University of Calgary, Medical Education Medical Student Course VI Lecture: Introduction to Pediatric Trauma Dr. Jonathan Guilfoyle Family Medicine Resident Academic Half-Day: Approach to Pediatric Trauma Dr. Jonathan Guilfoyle Pediatric Resident Academic Half-Day: Multi-trauma in the ED Dr. Jonathan Guilfoyle Emergency Medicine Resident Academic Half-Day: Pediatric Trauma: Pitfalls and Pearls Dr. Jonathan Guilfoyle PEM Fellow Academic Day: An Evidence Based Review of Severe TBI Dr. Jonathan Guilfoyle 12

13 4. Research The following research projects were in progress or completed during 2016: PUBLICATIONS: 1) Brooks B, Low T, Daya H, Khan S, Mikrogianakis A, Barlow K. Test or Rest? Computerized cognitive testing in the emergency department after pediatric mild traumatic brain injury does not delay symptom recovery. J Neurotrauma 2016 March 04 2) Zemek R, Barrowman N, Freedman S, Mikrogianakis A, Barlow K et al. Clinical Risk Score for Persistent Post Concussion Symptoms Among Children with Acute Concussion in the ED JAMA 2016 Mar08:315(10) 3) Khetani A, Brooks B, Mikrogianakis A, Barlow K Incorporating a Computerized Cognitive Battery into the Emergency Department Care of Pediatric Mild Traumatic Brain Injuries is it feasible? Pediatric Emergency Care 2016 Dec 7 4) Brooks B, Low T, Daya H, Khan S, Mikrogianakis A, Barlow K Test or Rest? Computerized Cognitive Testing in the Emergency Department After Pediatric Mild Traumatic Brian Injury Does Not Delay Symptom Recovery J Neurotrauma March 4 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) 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 3) Lopushinsky S, Lockyer L, Daodu O, Alvarez-Allende C, Brindle M, Weber B Outcomes of an Accelerated Care Pathway for Pediatric Blunt Solid Organ Injuries in a Public Healthcare System 4) Ferri-de-Barros F, Brauer C, Stelfox, T. Quality indicators in the Management of Supracondylar Humeral Fractures in Children: A family centered analysis of care 5) Lee P, Lam R, MacGillivray S, Cheng A, Guilfoyle J, Mikrogianakis A, Grant V. The Use of a Pediatric Trauma Checklist to Improve Clinical Performance in a Simulated Trauma Resuscitation: a randomized trial 13

14 6) MacGillivray S, Grey LM, Guilfoyle J, Lopushinsky S Unplanned Emergency Department/Urgent Care Centre Visit or Hospital Readmission within 30 days of discharge from a Pediatric Trauma Centre 14

15 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 2016 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? 15

16 6. Future Planning The 2017 year will focus on the following activities: Preparation for upcoming accreditation Continuing 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 Continuing to improve 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 Continuation of an Attending Physician focused, CME accredited, simulation based, professional development program Development and implementation of the Royal College Accredited, Trauma Resuscitation in Kids (TRIK) course 16

17 ACH Trauma Quality Indicators (ISS>12) 2016 Appendix A Alberta Children s Hospital Trauma Quality Indicators for 2016 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 n = n = n = /2014, n = /2013, 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 2016 n = n = n = /2014, n = /2013, 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 evidencedbased 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. 17

18 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 2016 n = n = n = /2014, n = /2013, n = %Yes %No If at any time the Pediatric Trauma Quality Management Committee feels that the Rural Hospital LOS is not acceptable, communication 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 an Alberta Trauma Services 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, 5 patients were transferred from within Calgary, 0 from Lethbridge, 1 from Red Deer and 2 from Medicine Hat resulting in a total (n=8) 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 2016 n = n = n = /2014, n = /2013, 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. RAAPID (Referral, Access, Advice, Placement, Information & Destination) 18

19 ACH Trauma Quality Indicators (ISS>12) 2016 protocols help mobilize transport more efficiently, but it is still not a mandatory service in Alberta. This indicator has also been a priority for Alberta Trauma Services. 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 2016 n = n = n = /2014, n = /2013, 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, south-eastern 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 the team 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. All transport times are audited by the Trauma Coordinator and the Transport Team Clinical Nurse Specialist. 19

20 ACH Trauma Quality Indicators (ISS>12) 2016 Resuscitative care: 6. Trauma Team Activation Major Trauma Team Activation # of Activations Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 2013/ 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 65 (compared to an average of 139 prior to the 2013 changes). Overcall (those not admitted) was 29%. Missed call (those that should have had an activation according to guidelines) was only 3%. We also monitor for undercalls, i.e. those patients that did not meet activation criteria but did have significant injuries and we have not found a significant number of undercalls since the implementation of our revised activation criteria. The over, under and missed call of Code 77 patients is monitored closely by the Trauma Coordinator and reported monthly at the Trauma Committee. 20

21 ACH Trauma Quality Indicators (ISS>12) 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 n = n = n = /2014, n = /2013, n = %Yes %No There is currently a No Direct Admit Policy for trauma patients meaning they should stop in the ED for an assessment. This policy was made to ensure that every patient gets an unbiased, good primary survey. If a patient was admitted to a referral hospital for more than 24 hrs prior to the transfer this policy does not apply. This past year the one patient had been an inpatient at the Foothills Medical Centre and was directly admitted for rehabilitation to the inpatient trauma unit. This was reviewed at the Trauma Quality Management 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 n = n = n = /2014, n = /2013, 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. 21

22 ACH Trauma Quality Indicators (ISS>12) Presence of ED nursing documentation every one (1) hour. After arrival at the trauma centre, was every (one) 1 hour 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 n = n = n = /2014, n = /2013, n = %Yes %No ED documentation continues to be a challenge but is considered to be important for patient care. This year the timeframe was changed from every 30 mins to every one hour to meet new guidelines from the National Trauma Data Bank. Note this is also the standard guidelines for ED documentation for all patients. 10. 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 n = n = n = /2014, n = /2013, 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 has been added to the trauma pack documentation to help improve compliance. 22

23 ACH Trauma Quality Indicators (ISS>12) 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 2016 n = n = n = /2014, n = /2013, n = %Yes %No This past year there were no patients that presented to the ED hypothermic. However 2 patients did not have their temperature documented this will be an education priority going forward. 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 2016 n = n = n = /2014, n = /2013, n = %Yes %No 23

24 ACH Trauma Quality Indicators (ISS>12) 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 2016 n = n = n = /2014, n = /2013, 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. 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 2016 n = n = n = /2014 n = /2013, n = %Yes %No This past year 6 of the 7 patients were appropriately admitted to the Pediatric Service according to the Trauma Admission Guidelines. One patient was transferred to the appropriate surgical service within a few hours of admission. 24

25 ACH Trauma Quality Indicators (ISS>12) 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 2016 n = n = n = /2014, n = /2013, n = %Yes %No 16. 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 2016 n = n = n = /2014, n = /2013, n = %Yes %No 25

26 ACH Trauma Quality Indicators (ISS>12) Any laparotomy procedure performed. Did the patient require a laparotomy? Exclusions: None Inclusions: n = all major trauma patients. Indicator Yes No 2016 n = n = n = /2014, n = /2013, 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 for blunt abdominal trauma in pediatrics. 18. 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 2016 n = n = n = /2014, n = /2013, n = %Yes %No Note that the total number of femur fractures is for ISS > 12 patients only isolated femur fractures do not qualify as their ISS is 9. 26

27 ACH Trauma Quality Indicators (ISS>12) 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 2016 n = n = n = /2014, n = /2013, n = %Yes %No This patient had a very complicated open fracture that was sent to the Foothills Medical Centre for their expertise to repair. This was deemed appropriate by the Trauma Quality Management Committee. 20. 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 2016 n = n = n = /2014, n = /2013, n = %Yes %No This patient was taken back to the OR within 48 hours of initial surgery under the expertise of the trauma surgery department. This was deemed appropriate as per the Trauma Quality Management Committee. 27

28 ACH Trauma Quality Indicators (ISS>12) 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 2016 n = n = n = /2014 n = /2013 n = %Yes %No A trauma tertiary survey (TTS) performed by the Trauma Surgery NP, Fellow or Resident at 24 hours of admission to the trauma centre helps to keep missed injuries to a minimum. In the past year there was only one missed injury. This occurred in a patient with multiple injuries who had a clavicle fracture that was not recognized initially. 22. 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 2016 n = n = n = /2014, n = /2013, n = %Yes %No 28

29 ACH Trauma Quality Indicators (ISS>12) 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 2016, n = , n = , n = /2014, n = /2013, n = %Yes %No 24. 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 2016 n = n = n = /2014, n = /2013, n = %Yes %No 29

30 ACH Trauma Quality Indicators (ISS>12) 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 2016 n = n = n = /2014, n = %Yes %No 2012/2013, n = 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 2016 n = n = n = /2014 n = %Yes %No 2012/2013 n =

31 ACH Trauma Quality Indicators (ISS>12) 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 2016 n = n = n = /2014 n = /2013 n = %Yes %No 28. 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 2016 n = n = n = /2014, n = /2013, n = %Yes %No This year a patient was appropriately transferred to the PICU after deterioration on the inpatient unit. 31

32 ACH Trauma Quality Indicators (ISS>12) 2016 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 2016 n = n = n = /2014, n = /2013, 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. 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 2016 n = n = n = /2014, n = /2013, n = %Yes %No This past year one patient died in the ED after blunt thoracic injuries. An additional 2 patients died in the PICU after 24 hours; one due to a submersion injury and the other due to a severe head injury. All death cases were reviewed by the Trauma Quality Management Committee and care was deemed appropriate. 32

33 ACH Trauma Quality Indicators (ISS>12) 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 2016 n = n = n = /2014, n = /2013, n = %Yes %No 33

34 ACH Major Trauma Statistics (ISS>12) 2016 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 34

35 ACH Major Trauma Statistics (ISS>12) 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 6.6% 5 5.2% 6 6.3% % 3 7.5% In 2016, 40 major trauma patients (meeting criteria for inclusion in the trauma registry) were seen at the ACH. This volume is lower than the five-year average of 74 major trauma patients seen annually. This decrease was noticed in 2015 and was felt to be due to upgrading to the AIS 2005 coding system on January 1, 2015 in order to prepare for submission to the National Trauma Data Bank based in the US in the near future. We would like to also speculate that pediatric trauma numbers are lower in Southern Alberta due to Injury Prevention awareness campaigns. 35

36 ACH Major Trauma Statistics (ISS>12) 2016 This 2016 trauma volume represents 5.4% of all patients admitted to the ACH with injuries (n=747), which is a 2 % decrease from last year. The percentage of major trauma patients who are males (75.0%) were greater than females (25.0%). Major trauma patients referred in from other centers represented 40.0% of the major trauma volume for This is slightly lower than the five-year average of 43.4%. Length of stay for major trauma patients ranged between 1 and 108 days. Mean LOS of 10 days is equal to the five-year trend of 10. Median LOS of 5 days is consistent with the five-year trend of 5. The total ED LOS was hours, and lower than the five-year average of hours. Both the mean and median LOS were consistent with the five-year averages of 3.6 and 4.2 respectively. 40.0% of major trauma patients were admitted to the ICU, which is slightly higher than the fiveyear average of 38.1%. Total ICU LOS was 109 days, which is lower than the five-year average of 129. The mean ICU LOS (7) is higher than the five-year average of 4.8 and the median (5) is higher that the five-year average of 2.8. Both the mean (21) and median (17) ISS for major trauma patient from 2016 were slightly lower than the five-year averages of 22.6 (mean) and 19.6 (median). A total of 3 deaths were seen in major trauma patients in This represents 7.5% of major trauma volume, and is slightly lower than the five-year average of 7.8%. 36

37 ACH Major Trauma Statistics (ISS>12) 2016 Figure 1. Age and Gender Distribution for ACH Major Trauma Patients for 2016 # 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. In 2016 the majority of trauma patients were male. On average males comprised 61.3% of the major trauma population over a period of five years. Figure 2a. Age Distribution of <15 year olds admitted to Calgary Adult Hospitals 5 <15 year old Major Trauma Patients 4 # of Patients FMC PLC RGH SHC 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. This past year one patient went to the FMC from ACH for surgical management. All cases are reviewed by the Trauma Coordinator to deem appropriateness. 37

38 ACH Major Trauma Statistics (ISS>12) 2016 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). 38

39 ACH Major Trauma Statistics (ISS>12) Etiology of Injuries Mechanism of Injury (MOI) describes the nature of the injury; transportation, falls, violence, and other mechanisms of injury. Figure 3. Breakdown by Mechanism of Injury 2007/ / / Violence 6% Violence 10% Other 26% Other Falls 27% 25% Falls 22% Transport 41% Transport 43%. Violence 10% Other 22% Falls 29% Transport 39% Figure 3 shows the breakdown of the mechanism of injuries for the incidents in 2016 as compared to the historical trend. The biggest change this past year was a slight increase in transport related injuries and a decrease in falls. 39

40 ACH Major Trauma Statistics (ISS>12) 2016 Mechanism of Injury Transportation Figure 4. Transportation Statistics Railway 6% / Water 1% MRV 18% Cyclist 29% MVC 18% Pedestrian 29% Cyclist 24% MRV 11% Pedestrian 20% MVC 44% Figure 4 shows the breakdown of transportation-related injuries in 2016 as compared to the historical trend. Note: MRV is motorized recreational vehicle. A total of 17 patients (43% of major trauma patients) were involved in transportation-related incidents in Mortality: 12% 2 patients died. ISS ranged from 12 to 43. Mean ISS was 21 and median ISS was 17. Figure 5. Five-Year Trend for Transportation as the MOI MOI -Transportation % of Patients 60% 50% 40% 30% 20% 10% 0% 44% 50% 43% 26% 29% Years Figure 5 shows a 7% decrease in transportation-related incidents from

41 ACH Major Trauma Statistics (ISS>12) 2016 Figure 6. Transportation by Age Group / >14 6% 1 to 4 6% >14 4% <1 2% 1 to 4 16% 10 to 14 47% 5 to 9 41% 10 to 14 45% 5 to 9 33% Figure 6 shows the breakdown of transportation incidents by age groups in 2016 as compared to the historical trend. A significant decrease is noted in the age group 1 to 4. No patients <1 were seen in this category. In 2016: Age Group <1 (n=0, %) no patients in this age group. Age Group 1-4 (n=1, 6%) included 1 pedestrian. Age Group 5-9 (n=7, 41%) included 1 passengers, 3 pedestrians and 3 cyclists. There were 2 deaths in this age group. Age Group (n=8, 47%) 1 passengers, 2 cyclists, 1 pedestrian, 3 ATV related injuries and 1 railway related injury. Age Group > 14 (n=1, 6%) included 1 passenger. 41

42 ACH Major Trauma Statistics (ISS>12) 2016 Mechanism of Injury Falls Figure 7. Statistics for Falls as the MOI Same-Level 11% Other and Unspecified 11% 2016 Same- Level 18% 2012/ Other and Unspecified 3% Multi-Level 78% Multi- Level 79% Figure 7 shows the breakdown of fall incidents in 2016 as compared to the historical trend. There has been a 7% decrease in same-level falls and an 8% increase in other and unspecified falls. A total of 9 patients (23% of major trauma patients) were admitted for fall-related injuries. Mortality: 0% all patients survived. ISS ranged from 14 to 33. Mean ISS was 20 and the median ISS was 17. Figure 8. Five-Year Trend for Falls as the MOI % of Patients 40% 35% 30% 25% 20% 15% 10% 5% 0% MOI Falls 37% 35% 28% 23% 18% Figure 8 shows the comparison of falls as the mechanism of injury over the past five years. This past year there was a 5% increase but it is below the five year average of 28%. 42

43 ACH Major Trauma Statistics (ISS>12) 2016 Figure 9. Falls by Age Group / >14 34% <1 11% 1 to 4 11% >14 5% 10 to 14 24% <1 20% 10 to 14 22% 5 to 9 22% 5 to 9 24% 1 to 4 27% Figure 9 shows the breakdown of fall incidents by age groups in 2016 as compared to the historical trend. A significant increase is seen in the >14 age group and decrease in the <1 and 1-4 age group. In 2016: Age Group <1 (n=1, 11%) Patient fell off a change table. Age Group 1-4 (n=1, 11%) included 1 multi-level fall. Age Group 5-9 (n=2, 22%) included 2 multi-level falls. Age Group (n=2, 22%) included 1 multi-level fall and 1 fall in the other specified category from a skateboard. Age Group >14 (n=3, 34%) included 1 multi-level fall, 1 same-level fall and a fall in the other specified category from a longboard. 43

44 ACH Major Trauma Statistics (ISS>12) 2016 Mechanism of Injury Violence Figure 10. Violence as the MOI / Assault with object 25% Assault with Object 15% Unarmed assault 5% Self- Inflicted 7% Other & Unspecified 75% Other & Unspecified 73% Figure 10 shows the breakdown of violence-related incidents in 2016 as compared to the historical trend. Note the 10% increase assault with an object and no injuries in the unarmed assault and self-inflicted categories. A total of 4 patients (10% of major trauma patients) were admitted for violence-related injuries. Mortality: 0% all patients survived. ISS ranged from 16 to 21. The mean ISS was 18. The median ISS was 18. Figure 11. Five-Year Trend for Violence as the MOI % of Patients 16% 14% 12% 10% 8% 6% 4% 2% 0% MOI - Violence 15% 11% 9% 10% 7% Figure 11 shows a 5% decrease in violence related injuries in the past two years. 44

45 ACH Major Trauma Statistics (ISS>12) 2016 Figure 12. Violence Incidents by Age Group / <1 25% >14 15% 10 to 14 18% <1 40% 1 to 4 75% 5 to 9 7% 1 to 4 20% Figure 12 shows the breakdown of violence incidents by age groups in 2016 as compared to the historical trend. Although there is a large increase in the percentage of violent incidents for the 1-4 age group, the actual number of events remains low at only 3. Age Group <1 (n=1, 25%) 1 non-accidental trauma or intentional injury in this age category. Age Group 1-4 (n=3, 75%) 2 were non-accidental trauma, 1 was assault with an object. Age Group 5-9 (n=0, 0%) no patients in this age category. Age Group (n=0, 0%) no patients in this age category. 45

46 ACH Major Trauma Statistics (ISS>12) 2016 Mechanism of Injury Other Figure 13. Statistics for Other Mechanism of Injury / Submersion & Drowning 10% Other & Unspecified 10% Animal 20% Inhalation & Ingestion 2% Submersion & Drowning 11% Fire & Explosion 6% Other & Unspecified 10% Animal 20% Mechanical 60% Mechanical 51% Figure 13 shows the breakdown of other mechanism of injuries in 2016 as compared to the historical trend. This past year there were no inhalation & ingestion or fire & explosion related injuries. A total of 10 patients (25% of major trauma patients) were admitted for other mechanism of injuries. Mortality: 10% 1 patient died. ISS ranged from 16 to 35. For survivors, the mean ISS was 22 and the median ISS was 20. For non-survivors, the mean ISS was 34 and median ISS was 34. Figure 14. Five-Year Trend for Other Mechanism of Injury % of Patients 35% 30% 25% 20% 15% 10% 5% 0% MOI - Other 30% 25% 18% 21% 21% Figure 14 shows a slight increase in the number of patients whose injuries are caused by animal, burn, inhalation, submersion injury, and mechanical-related incidents when compared to the five year average of 23%. 46

47 ACH Major Trauma Statistics (ISS>12) 2016 Figure 15. Other Mechanism by Age Group / <1 10% >14 6% <1 4% 10 to 14 10% >14 20% 5 to 9 30% 1 to 4 30% 10 to 14 34% 5 to 9 28% 1 to 4 28% Figure 15 shows the breakdown of incidents involving other mechanism of injury by age groups in 2016 as compared to the historical trend. There was an increase in all categories except the 1-4 and groups. In 2016: Age Group <1 (n=1, 10%) included 1 submersion injury that died. Age Group 1-4 (n=3, 30%) included 1 burn and 2 animal-related injuries. Age Group 5-9 (n=3, 30%) included 1 struck by a falling object and 2 striking accidentally against objects or persons. Age Group (n=1, 10%) included 1 struck by a falling object. Age Group >14 (n=2, 20%) included 2 striking or struck by object or persons in sports. 47

48 ACH Major Trauma Statistics (ISS>12) 2016 Type of Injury Type of Injury indicates whether the most serious injury is blunt, penetrating, burn, or other type of injury (submersion or asphyxia). Figure 16. Type of Injury 100 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 90% of major trauma population. More penetrating injuries with ISS > 12 were seen this year. Note that submersion is reported as other. Figure 17. Five-Year Trend for Type of Injury Type of Injury - Five Year Trend Total Pts = 373 # o Patients Fiscal Years Blunt Penetrating Burn Other Figure 17 compares the different types of injuries from 2012/2013 up to

49 ACH Major Trauma Statistics (ISS>12) Penetrating Trauma All ISS # of Patients Fiscal Years In 2012 all AHS trauma centers began capturing data on all penetrating traumas regardless of ISS in the Alberta Trauma Registry. In 2016 there were 4 penetrating traumas at ACH. Place of Injury Figure 18. Statistics for Place of Injury / Unspecified 5% Unspecified 4% Farm 5% Street 30% Home/Res Inst 37% Street 26% Home/Res Inst 33% Recreation 15% Other 10% Public Building 3% Recreation 20% Public Building 7% Other 5% Figure 18 shows where the patients were injured in 2016 demonstrating an increase in the home/residential and a street categories with decreases in recreation, public building and farm categories. 49

50 ACH Major Trauma Statistics (ISS>12) Referrals and Emergency Management Referral Patterns Out of 373 major trauma patients from 2012/2013 to 2016, a total of 162 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 21 patients (13% of total referrals) and Red Deer Regional Hospital with a total of 16 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 = 38 Blairmore - Crowsnest Pass Cardston Municipal Fort Macleod H.C.C Lethbridge Regional Pincher Creek Municipal 1 1 Taber H.C.C Region 2 - Palliser Health Region, Total = 15 Brooks Health Centre Medicine Hat Regional Region 3 - Calgary Health Region, Total = 53 Banff - Mineral Springs Black Diamond Oilfields General Calgary Foothills Calgary General/Peter Lougheed Calgary Rockyview General Calgary South Health Campus South Calgary Health Centre 1 1 Canmore General Claresholm General High River General Strathmore - Valley General 3 3 Cochrane Urgent Care Okotoks Urgent Care

51 ACH Major Trauma Statistics (ISS>12) 2016 Region 4 - David Thompson Health Region, Total = 31 Didsbury Mountain View H.C. 1 1 Drumheller Regional Hanna H.C.C. 1 1 Olds General 1 1 Red Deer Regional Rocky Mountain House Stettler General Sundre General 1 1 Three Hills H.C.C British Columbia, Total = 23 Cranbrook Regional Hospital Elkford Health Centre 1 1 Fernie District Hospital Invermere District Hospital Penticton Regional Hospital 1 1 Salmon Arm, Shuswap Hospital 1 1 Saskatchewan, Total = 1 Regina 1 1 Out of Country, Total = 1 Mexico

52 ACH Major Trauma Statistics (ISS>12) 2016 Mode of Transport for Patients Arriving at ACH Figure 19. Direct from the Scene / Private/Walk-in 15% Private/Walk-in 29% Helicopter 17% Ground 54% Fixed-wing 11% Helicopter 10% Ground 64% Figure 19 shows the patients arriving at ACH ED directly from the scene in 2016 as compared to the historical trend. Note the increase in helicopter and private vehicle transports for direct from the scene patients and the absence of fixed-wing patients. Figure 20. Referrals / Helicopter 12% Fixed-wing 19% Ground 69% Fixedwing 19% Helicopter 21% Private/Walk-in 2% Ground 58% Figure 20 shows the patients who were referred to ACH for further treatment in 2016 as compared to the historical trend. Note the decrease in helicopter transports and the increase in ground ambulance transports for referral patients this past year. The appropriateness of the means of transport is part of the review process for each major trauma patient. 52

53 ACH Major Trauma Statistics (ISS>12) 2016 Figure 21. Ground vs Air 70% Ground vs Air 60% 50% 40% 30% 20% Ground Air 10% 0% Ground ambulance transported 24 patients (60%) major trauma patients in 2016, which is slightly lower than the previous fiscal year. Their ISS was a mean of 22 and median of 18. Patients transported by air had an ISS mean of 23 and median of 17. Month and Time of Arrival Figure 22. Month of Arrival Comparison of ED Arrival by Month for 2016 with 2012/2013 to Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Mean 12/ There was a decrease in major trauma patients arriving in ACH ED in all months except November in 2016 as compared to the historical trend. 53

54 ACH Major Trauma Statistics (ISS>12) 2016 Figure 23. Day of Arrival Comparison of Arrival by Day for 2016 with 2012/ Sun Mon Tues Wed Thu Fri Sat Mean 12/ In 2016, there was a decrease in major trauma patients arriving in ACH ED all days, when compared to previous years. This is due to decreased number of overall patients seen. Sunday continues to be the busiest day of the week. Time of Arrival Figure 24. Time of Arrival Comparison of Time of Arrival for 2016 with 2012/ :01-08:00 08:01-16:00 16:01-24:00 Mean 12/ Figure 24 shows marked decreases in all time categories. Historically, the majority of patients arrive between 16:01-24:00. 54

55 ACH Major Trauma Statistics (ISS>12) 2016 Figure 25. Time of Arrival of Patients Arriving Directly from the Scene Comparison of Patients Arriving Directly From the Scene for 2016 with 2012/ :01-08:00 08:01-16:00 16:01-24:00 Mean 12/ 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 2016 Table 3. Diagnostic Imaging A total of 31 patients (78% of major trauma patients) went urgently (within 6 hours of arrival) to CT for imaging of the following body locations. This is slightly higher than the 5 year average of 74% for urgent CT s for major trauma patients. Diagnostic Imaging CT Locations # Patients Percent of Total Patients (n=31) Percent of Positive Results Head 22 71% 91% Abdomen 20 65% 55% Pelvis 20 65% 55% Spine 22 71% 25% Chest 9 29% 89% Face 5 16% 80% Note: Some patients had CT s done on multiple body locations and also may have had multiple CT s done on the same body part. Also note some patients had CT s done at referral centres prior to arrival to ACH. 55

56 ACH Major Trauma Statistics (ISS>12) 2016 Figure 26. Time of Day of Urgent CT # of Patients Time of Day of Urgent CT (within 6 hours of arrival, n=31) :01-08:00 08:01-16:00 16:01-24:00 Time of Day 26 Figure 26 compares the time of urgent CT s from 2012/2013 to Note the consistency that the majority of urgent CT s are performed between 16:01-24:00 which is when the majority of major trauma patients arrive at the ACH ED. In 2016, 84% (n=26) of patients had CT s done from 16:01 to midnight. Only 10% of patients had CT s from midnight to 8:00 AM and 6% 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 # of Patients Monday Tuesday Wednesday Thursday Friday Saturday Sunday 56

57 ACH Major Trauma Statistics (ISS>12) 2016 Figure 27 compares the day of the week CT was performed from 2012/2013 to In 2016 there is a decrease in the CT s performed on every day except Tuesdays and Sundays, which were equal to the previous year. Figure 28. CT done within 1 hour of ED Arrival CT within 1 hour of ED Arrival # of Patietns Yes No / Year Figure 28 shows the past four years comparisons if CT was done within one hour of arrival at ACH ED. In % 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, 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 2016 Table 4. Non-operative Procedures Performed on Patients while in ACH ED Non-Operative Procedures # Patients Percent of Total Patients (n=39) Gastric Tube Insertion 7 18% Foley Catheter Insertion 8 21% Intubation 4 10% Blood Product Administration 4 10% Chest Tube Insertion 4 10% Many patients have these types of non-operative procedures done at referral centres prior to transport, so are therefore not represented in this table. 57

58 ACH Major Trauma Statistics (ISS>12) 2016 Patient Disposition from ED Figure / Died in ED 2% ICU 32% Died in OR 1% Died in ED 2% ICU 28% Ward 55% OR/ICU 5% OR/Ward Direct 3% Admit 3% Ward 56% OR/ICU 4% OR/Ward 3% Direct Admit 6% Figure 29 shows the breakdown of patient disposition from the ED in 2016 as compared to the historical trend. This past year, there was a decrease of direct admissions when compared to the past five years. There was one ED death in 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 (38%) of trauma patients went to the OR. This is higher than the 5 year average of 31%. Note the total OR hours have decreased this past year as compared to 2015, and are well below the 5 year average of