ANNUAL REPORT

CENTRAL ZONE TRAUMA PROGRAM 2012-2013 ANNUAL REPORT Prepared by Brenda Wiggins and Kyla Hoogers

Table of Contents Vision and Mission... 3 Director s Message... 4 Summary 2012-2013 Report... 5 Education... 6 Accomplishments in 2012-2013... 6 How data was collected... 6 Who qualifies for the Registry... 7 How the Injury Severity Score (ISS)is calculated?... 7 RDRH Trauma Activation Guidelines... 8 Trauma Activation... 9 Total number of Trauma Patients... 10 When did the injuries occur?... 11 Mechanism of Injury... 12 Type of Injury... 13 Mechanism of Injury Comparison... 14 Place of Occurrence... 15 Patient Gender... 16 Injury vs. Alcohol... 17 Seatbelt use/sports related injury... 18 Mode of Arrival... 19 Non operative procedures/length of Stay... 20 RDRH Admissions... 21 Admission by Practitioner... 21 ICU admissions... 22 Admission vs. Transfer... 23,24 Pediatric Trauma... 25 Disposition... 26 Trauma Deaths... 27 Performance Improvement and Patient Safety(PIPS)... 28 Central Zone Audit Filters... 28 PIPS Comments... 31 Future Goals... 31 2

Alberta Health Services Vision and Mission Vision, Mission, Values Our Vision, Mission and Values are core statements describing the overall purpose of our organization, how we operate, and what keeps us moving forward. It clarifies what we do, who we do it for, and why we do it. Our Mission To provide a patient-focused, quality health system that is accessible and sustainable for all Albertans. Our Values Alberta Health Services' core values have one thing in common: the quality of patient care. Our seven values - respect, accountability, transparency, engagement, safety, learning and performance - drive us, and unite us. Central Zone Trauma Program Vision To provide outstanding Trauma care Central Zone Trauma Program Mission Our mission is to establish and manage a systematic approach to trauma care in the Central Zone. This will be achieved by using best practices and striving for optimal outcomes, focusing on acute care, rehabilitation and injury prevention. We support the Provincial trauma initiative in getting the injured person to the right treatment at the right facility in the shortest amount of time 3

Director s Message Not surprisingly, the number of traumatic injuries seen in Central Alberta increased again over the past year. Both volume and acuity have been on the rise since we started tracking numbers through the Trauma Program. Despite that depressing fact, there are lots of positive accomplishments to focus on. At the Red Deer Regional Hospital Centre we continue to give great care to these patients. Every year we positively affect morbidity and mortality with the dedication, care and compassion of all our team members. In the outlying regions, EMS and peripheral hospitals continue to be frontline in providing quality emergent trauma care, stabilizing sick patients and ensuring safe travel to definitive care when necessary. Provincially, the trauma committee provides a great forum to foster cooperation and discussion of how to best move and care for our patients smoothly within the trauma system. Education continues to be our main mandate and we need to continue to push to ensure sharing of knowledge to all corners of our region to ensure standard of care continues for all. Despite great successes like the annual Regional Trauma Education Day, we need to continue to have regular learning opportunities on site at peripheral hospitals. Once again, I want to thank the administrative team of the Central Zone Trauma program for all the tireless work they put in to ensuring quality care for trauma patients in Central Alberta. We continue to grow as a program, and we need to as the numbers don t stop growing with us. Lyle Thomas MD, CCFP(EM) Emergency Physician, RDRHC Medical Director, Central Zone Trauma Program 4

Summary 2012-2013 Report The 2012-2013 year was the busiest ever. Our total major trauma increased by another 21% from the previous year. As the trauma system in Alberta continues to evolve we strive to provide optimal trauma care to our patients each and every day. We are participating in in-house education and struggling to provide education to rural non trauma hospitals. The PIPS (Performance Improvement and Patient Safety) consists of review by the Trauma Medical Director and Trauma Coordinator. We continue to work on getting a committee of peers for this task including representation of the rural hospital sites. It is our hope that in the next year this can be achieved. The number of patients being transferred out to a higher of level of care is holding steady in the last 3 years. 41% of trauma patients are being transferred to a higher level of care. Penetrating trauma with an ISS 12 has increased by 2% this year. We have begun to collect all penetrating trauma into the registry therefore should be able to assess the trends in upcoming years. As always we strive to provide the best care possible and wish to be transparent in doing so. The following report summarizes the activity of trauma in the Central Zone for the 2012-2013 fiscal year. Brenda Wiggins RN Central Zone Trauma Program Coordinator Acknowledgements: Debbie Westman-Acute Care Manager of the Emergency Department and Trauma Manager Lyle Thomas-Central Zone Trauma Medical Director and RDRHC Emergency Department Physician Brenda Wiggins-Central Zone Trauma Coordinator Kyla Hoogers-Central Zone Trauma Data Analyst Teresa Thomson-Central Zone Trauma Data Analyst Brenda Hamilton-Central Zone Trauma Secretary Red Deer Emergency Staff-There are always challenges in providing excellent patient care and one of the biggest challenges at the RDRHC in the past year seems to be the overcrowding of the emergency department. The staff in the emergency department provides the very best care to the trauma patients and this is the time to thank them. With numbers climbing each year they give their best to every patient and we in the Trauma Program appreciate the expertise and caring they exhibit each day. 5

Education Telehealth sessions TNCC x 3 rural hospitals in Central Zone TNCC x2 Red Deer Regional Hospital Emergency department Orientation Trauma Education for Unit 21 Annual Trauma Education Day Accomplishments in 2012-2013 Revision of the process of collecting Performance Improvement and Patient Safety (PIPS) information Burn Guidelines completed and distributed to the Rural Acute care managers Spinal Precautions and Log rolling procedure put online and available to all of the old DTHR and East Central Regions How Data was collected Each month a report is run from the meditech system on all the emergency department patients. Once this is run, the Trauma Coordinator filters out the trauma patients and requests charts to review. The charts are reviewed by the Trauma Coordinator and further culling of those charts is done if they are an ISS of 12 or more. The Trauma Data Analyst will review and enter them into the trauma registry. Only the ISS 12 is submitted to the Alberta Trauma Registry and the National Trauma Registry. The Alberta Trauma Registry is housed at Alberta Center for Injury Control and Research (ACICR) in Edmonton, Alberta. The National Trauma registry is housed in Ottawa, Ontario with CIHI (Canadian Institute for Health Information). The National Trauma Registry will no longer keep the detailed trauma information that it has in the past. Currently the Provincial Trauma Committee is trialing the use of TQIP from the United States. Calgary Foothills will be submitting data to this entity. The Trauma registry is a requirement for any accredited trauma center, by the Trauma Association of Canada. The trauma registry uses Collector software that was developed in the United States by Digital Innovations. It complies information entered by the data analyst. It is useful to provide statistical information for Performance improvement and injury prevention activities as well as showing trends in traumatic injuries. 6

Who qualifies to be in the registry? One of the requirements to qualify for the trauma registry is to have an injury severity score of 12. This is an essential requirement for the Alberta and National Trauma Registry. If any of the following conditions exists the patient is included in the Central Zone Trauma registry. ISS 12 and admitted to the Red Deer Regional Hospital Transferred to a higher level of care Trauma Death in the Emergency Department In the Central Zone we collect any patient that is transferred to a higher level of care even if they don t have an ISS of 12. Often we don t have enough time to thoroughly investigate and diagnose these patients because their injuries are so severe they need transfer to a higher level of care. The Level 1 trauma center will determine their ISS and enter them into the Alberta and National Registry if they have an ISS 12. Abbreviated Injury Score (AIS) How the Injury Severity Score (ISS) is calculated? AIS is anatomically based scoring and the score is not contingent on long-term outcome. It assesses the severity of single injuries. There is a scale ranking the level of severity: 1=minor 2=moderate 3=serious 4=severe 5=critical 6=maximum (currently untreatable) Death is not part of the severity scale; therefore, dying doesn t automatically mean a score of 6 Injury severity score: ISS (Injury Severity Score) is an anatomical scoring system that provides an overall score for patients with multiple injuries. Each injury is assigned an Abbreviated Injury Scale (AIS) and is allocated to one of six body regions (Head, Face, Chest, Abdomen, Extremities including pelvis, and External) Only the highest score in each body region is used. The three most severely injured body regions have their score squared and added together to produce the ISS score. The range of the ISS is 0-75. The higher the score the more injured the patient. 7

Vital Signs and Level of Consciousness: RDRH Trauma Activation Guidelines Anatomy of Injury Mechanism of Injury Glasgow Coma Scale <14 or Systolic Blood Pressure <90 or Respiratory Rate <10 or >29 (<20 in infant < one year) All penetrating injuries to head, neck, torso, and extremities proximal to elbow and knee Flail chest 2 or more proximal long-bone fractures Obvious mid shaft femur fracture Crush, degloved or mangled extremity Amputation proximal to wrist and ankle Unstable pelvic fracture Open or depressed skull fracture Paralysis Falls -Adults: > 20 feet (one story is equal to 10ft) -Children: >10 ft. or 2-3 times the height of the child High risk auto crash -Intrusion: >12 inches occupant site; > 18 inches any site -Ejection (partial or complete) from automobile -Death in same passenger compartment Auto vs. pedestrian/bicyclist thrown, run over, or with significant (>20mph) impact Motorcycle crash >20mph Special Patient or System Considerations (consider these criteria in combination with the above criteria) Age -Older Adults: Risk of injury death increases after age 55 -Children Anticoagulation and bleeding disorders Burns -2 nd degree and 3 rd degree totaling> 20% TBSA -Airway/Facial Burns Time sensitive extremity injuries End-stage renal disease requiring dialysis Pregnancy >20 weeks 8

Trauma Activation Trauma Team Activation 2008-2013 60% Percentage of patients per year 56% 55% 52% 52% 2008-2009 2009-2010 2010-2011 2011-2012 2012-2013 The trauma team consists of an Emergency Department Physician, 3 nurses, 1 respiratory therapist, lab technician, unit secretary and radiology technician all responding to the trauma activation initiated by the triage nurse. If additional specialties are required they are paged by the unit secretary. If neurosurgery, spine surgery or cardiovascular surgery is required, then RAAPID North or South is called to arrange transfer. The trauma team was activated 55% of the time when presented with a major trauma patient. Using the trauma activation guidelines there were 67% of the trauma patients that met criteria for trauma activation. 31% of the patients meeting criteria were missed, activation was not called. 9

How many patients were seen at the Red Deer Regional Hospital Emergency Department? Total Number of Trauma Patients 2008 to 2013 143 104 113 67 81 2008-2009 2009-2010 2010-2011 2011-2012 2012-2013 The total number of patients seen in the RDRH Emergency Department in 2012-2013 with an ISS (Injury Severity Score) of 12 that were admitted, transferred or died was 143. There were 1150 minor and major trauma patients seen at RDRH Emergency Department for the fiscal year 2012/13. These were admissions, transfers and deaths regardless of the ISS (Injury Severity Score) 83% of the 143 trauma patients had an ISS of 16 and above. The average age of the trauma patients was 43 years. 1373 charts were reviewed to capture the 143 trauma patients that qualified for the Central Zone Trauma Registry. The acuity of the trauma patients is unchanged from last year. 10

Patients When did these Injuries Occur? 25 Number of Trauma Patients by Month April 2012 to March 2013 20 21 15 10 14 15 15 12 15 11 11 10 5 8 4 7 0 With the exception of a busy month in June and the slow month of February the distribution of patients is steady through the year. Trauma by Days of the Week April 2011 to March 2013 18 27 11 15 23 21 12 16 18 15 15 19 18 25 2011-12 2012-13 Saturday and Sunday are the busiest days of the week and Tuesdays come in a close third.. After review of Tuesday patients there is no explanation an increase in the middle of the week. They are not transfers in from the non trauma hospitals and no injuries were related. 11

How did the Injuries Occur? Mechanism of Injury April 2011 to March 2012 48% 33% Transportation Falls 11% 8% Assault/Selfharm Other The top 3 mechanisms of Injury remain unchanged from last year; 48% transportation, 33% falls, 11% assaults/self harm. *Transportation includes off road vehicles, animals used for transport and bicycles. 'Other' includes fire, explosions, drowning, and animal attacks. 12

Type of Injury April 2012 to March 2013 92% Blunt Penetrating Burns Other 4% 1% 3% Definitions: Blunt trauma refers to the physical trauma caused by impact with another object. Usually caused by MVC, falls or assaults. Injurys may include contusions, abrasions,fractures. Penetrating injury is an injury occuring when an object pierces the skin and enters the body, creating an open wound. Burns are any injury to the body caused by thermal, chemical or radiation. The burn thickness (superficial, partial thickness, full thickness) and percent of the body is used to measure severity. Can be combined with penetrating and/or blunt trauma. Blunt injury is the most comman Type of Injury in Central Zone and frequency of occurance has not changed in the past five years. Penetrating injury has increased by 2% from last year. Not all penetrating injury admissions are captured because the ISS does not reach 12. 13

Number of Patients 5 Year Comparision of Mechanism of Injury 60 50 40 30 20 10 Mechanism of Injury Injury Severity Score >12 April 2008 to March 2013 0 Motor vehicle Falls Assault/S elf-harm Bicyclerelated Animalrelated Off-road vehicle Other Unknown 2008/2009 28 14 8 2 4 8 2 0 2009/2010 40 12 7 0 4 8 10 0 2010/2011 33 23 13 2 10 5 1 1 2011/2012 40 31 19 4 6 4 8 1 2012/2013 51 47 12 7 7 7 12 0 The above chart compares five years of the major categories of Mechanism of Injury with little variation. There was a slight increase in the MVC and Falls. The graph below supports trauma affects primarily the 1-44 yrs age range. NUMBER OF PATIENTS 20 15 10 5 Mechanism of Injury by Age Range April 2012 to March 2013 0 < 15 15-24 25-34 35-44 45-54 55-64 65-74 75-84 85 + Transportation* 3 18 16 5 11 11 2 4 1 Falls 3 2 3 6 4 7 5 8 7 Assault/Self-harm 0 3 4 2 0 2 0 0 0 Other** 4 1 2 5 0 2 2 0 0 Total 10 24 25 18 15 22 9 12 8 14

Where did the Injuries Occur? PLACE OF OCCURRENCE INJURY SEVERITY SCORE > 12 April 2012 to March 2013 24% 36% 22% 3% HOME 3% 3% 3% 5% STREET/HIGHWAY SCHOOL/PUBLIC INSTITUTION/ATHLETIC AREA INDUSTRIAL/CONSTRUCTION AREA OTHER TRADE/SERVICE AREA FARM UNSPECIFIED/UNKNOWN The injuries occurring in the street/highway and at home based on the top 3 mechanisms of injury; MVC, falls, and assault/self harm. 22% of injuries place of occurrence is unknown or unspecified. This is unchanged from last year, the cause being lack of documentation. 15

Who is getting injured? Trauma Patients by Gender April 2011 to March 2012 71% 29% Males Females 101 (71%) males out of 143 of the trauma patients were treated in the Emergency Department at the RDRHC. 42(29%) out of 143 trauma patients were females being treated for injuries. 16

Injury vs. Alcohol Use ETOH Use April 2012 to March 2013 The number of patients, from which the data was compiled, is as follows: 8% ETOH levels < 17.0 = 19 ETOH levels > 17.0 = 12 ETOH levels not drawn = 105 ETOH levels not applicable (patient was under 10 years of age) = 7 13% 5% 73% ETOH levels > 17.0 ETOH levels < 17.0 ETOH levels not drawn Not applicable - < 10 years of age To be considered intoxicated the legal limit is 17.0 mmol/l. 73 % of the trauma patients seen in RDRH Emergency Department did not have alcohol levels drawn. Of those that had levels drawn 13% were over the legal limit. 17

Seatbelt Use and Sports-related Trauma Seatbelt Use All Injury Severity Scores Included 2008 to 2012 20% 28% 41% 39% 26% Percentage of Patients 70% 54% 57% 50% 65% No Seatbelt Seatbelt Unknown 18% 10% 11% 9% 2% 2008-2009 2009-2010 2010-2011 2011-2012 2012-2013 Seatbelt use has improved from last year. 9% are unknown/undocumented as to whether seatbelts were used. Sports-related Trauma April 2010 to March 2013 ATV/Dir tbike Bicycle s Hockey Horserelated Skateb oarding Snow Sports Other 2012-2013 8 8 3 4 0 1 8 2011-2012 2 3 0 4 0 1 5 2010-2011 5 2 1 8 2 5 2 ATV/dirt bike injuries continue to increase. 'Other' relates to isolated incidences of injury caused by water sports, parachuting, play unspecified etc. 18

How did the Injured get to RDRH Emergency Department? Arrival by Ambulance vs Arrival by Private Vehicle or Walk-in 2008 to 2013 83 84 NUMBER OF PATIENTS 64 49 49 38 18 21 18 8 10 21 22 11 12 2008/2009 2009/2010 2010/2011 2011/2012 2012/2013 BY AMBULANCE FROM SCENE BY PRIVATE VEHICLE/WALK-IN FROM SCENE TRANSFERRED IN FROM NON-TRAUMA CENTRE 59% of trauma patients are direct from the scene of injury compared to 73% last year. The patients arriving from a non trauma center has increased from 11% to 15%. Walk in directly to emergency triage has also increased to 26% from 16%, from last year. 19

28 26 24 22 21 21 18 9 9 Red Deer Regional Hospital The top 3 procedures in the trauma patients that arrive at RDRH Emergency Department are; CT scan, Peripheral IV start and C Spine Immobilization. Blood products were used 22 times for trauma resuscitation but only 3 times was the massive transfusion protocol documented in orders to be followed for the resuscitation. 124 113 Non-operative Procedures Performed in the Emergency Department April 2012 to March 2013 85 68 4 4 4 3 2 2 Length of Stay April 2012 to March 2013 54 Number of Patients 16 3 2 2 0 7 1 to 5 6 to 10 11 to 15 16 to 20 21 to 25 26 to 30 More Length of Stay (days) than 30 64% of trauma patients had a stay of 5 or less days. The seven patients that had more than 30 days stay were generally palliative. 20

Number of Patients RDRH Admissions Number of Patients by Admission 32 Service April 2012 to March 2013 Number of Patients 16 11 9 5 5 4 2 1 General Surgery is the top admitting service with 32/143 of the trauma patients with an ISS of 12 Trauma Patient Admissions by Classification of Practitioner April 2012 to March 2013 67 18 0 15 Out of all the patients admitted by General Practitioners (GP), none had an ISS of less than 12. Fourteen patients had injury severity scores of 16 or greater and four of those had injury severity scores of 25. Patients with an ISS < 12 have been included because they are those with penetrating wounds, or are those who are later transferred to a higher level of care, but are lacking the documentation needed to provide an ISS that appropriately reflects the extent of their injuries 21

Admissions to ICU April 2008 to March 2013 ISS > 12 Number of Patients 7 10 8 7 9 2008-2009 2009-2010 2010-2011 2011-2012 2012-2013 Injury Severity Score Ranges for ICU Visits April 2012 to March 2013 4 Number of Patients 2 3 1 1 0 Injury Severity Score ICU admissions remain constant. Their ISS scores were generally between 17 and 35. The total number of ICU days used by trauma patients ISS > 12 was 27days. (April 2012 to March 2013). The total number of days for the previous year was 43. The high number of days for the 2011-2012 year can be explained by the fact that one patient spent 20 days in ICU. 22

Number of Patients Number of Patients Transfers to a Higher Level of Care Trauma Patients Admitted vs Transferred to a Higher Level of Care 2008 to 2013 ADMITTED TO RDRHC 85 TRANSFERRED TO HIGHER LEVEL OF CARE 30 44 37 35 59 58 45 48 58 2008/2009 2009/2010 2010/2011 2011/2012 2012/2013 Of the 41% of trauma patients transferred to a higher level of care. 56% of the adults went to the Foothills Medical Center. A higher number of pediatric cases went to the Stollery Hospital in Edmonton, a change from last year when it was an equal distribution between Alberta Children's and Stollery. Trauma Patients Transferred to a Higher Level of Care All Injury Severity Scores Included April 2012 to March 2013 56% 19% 9% 4% 12% FOOTHILLS MEDICAL CENTRE UNIVERSITY OF ALBERTA HOSPITAL ROYAL ALEXANDRA HOSPITAL ALBERTA CHILDREN'S HOSPITAL STOLLERY CHILDREN'S HOSPITAL 23

17% 15% 32% 34% 32% 83% 85% Trauma Patients Transferred to a Higher Level of Care Injury Severity Scores > 12 vs. Injury Severity Scores < 12 April 2008 to March 2013 68% 66% 68% 2008-09 2009-10 2010-11 2011-12 ISS less than 12 7 6 19 25 27 ISS greater than or equal to 12 33 33 40 48 58 2012-13 In addition to the 143 trauma patients with an ISS of 12, there were 27 patients transferred to a higher level of care. These 27 patients did not have an ISS of 12 or higher because all injuries had not been identified due to the urgency of transfer to a Level One Trauma Center. They were assessed and treated at a Level one Trauma Center and if appropriate put into their trauma registry. 24

Number of Patients Pediatric Trauma Pediatric Patients Admitted vs Transferred 2008 to 2011 13 4 3 3 8 6 4 7 5 4 ADMITTED TRANSFERRED 2008/2009 2009/2010 2010/2011 2011/2012 2012/2013 The total number of pediatric patients with an ISS of 12 was 17 for the year of 2012-2013. 4 patients were admitted to the Red Deer Regional Hospital and 13 were transferred out to a higher level of care. 25

Home From ER to Trauma Centre Level 1 or 2 From Inpatient Unit to Trauma Centre Level 1 or 2 To Non-Trauma Centre Other * Died Rehab Disposition 66 58 Discharge Disposition April 2012 to March 2013 Number of Patients 6 6 3 3 1 58 trauma patients with an ISS 12 were transferred to a higher level of care. 85 trauma patients were admitted to Red Deer Regional Hospital. Of the admitted patients - 6 patients went to a higher level of care from an inpatient unit -6 patients were transferred to a non trauma center -3 died -1 went to rehab -3 others went to foster care, correctional facility, and a nursing home 26

Trauma Deaths Trauma Deaths 2008 to 2013 3 2 2 7 2 2 Died > 24 hours after admission Number of Patients 1 3 3 1 2 1 Died < 24 hours after admission Died in Emergency 0 3 trauma related deaths occurred in 2012-2013. One died as an admitted patient <24 hrs after admission to the hospital. Two trauma patients died >24 hrs after admission to the hospital. Mortality rate for 2012-2013 was 2.09% 27

Performance Improvement and Patient Safety (PIPS) A retrospective review of all the charts with an ISS of 12 and trauma deaths are screened and pulled by the trauma coordinator and the data analyst. All trauma deaths are reviewed. Audit filters/performance indicators assist in flagging charts for review. In addition any trauma patient that is flagged by a staff members concern may be pulled and reviewed. The Trauma Medical Director and the Trauma Coordinator do a retrospective review of these charts to identify any issues affecting the quality of patient care. If any issues are identified, the processes to resolve the issue are dealt with in the following ways: The Caregivers are spoken with directly EMS issues are discussed with the Central Zone EMS director The Hospital Quality Improvement Committee may be contacted about issues that are becoming trends. Processes can be developed via policy or education to resolve the specific identified issues. Central Zone Audit Filters 2012-2013 1. Are all pre hospital ambulance reports from all phases of patient transport present on the medical record? 2. Was q30minute chart documentation present for patient beginning with ER, including time in radiology, up to admission to the OR, ICU, ward, death or transfer to another hospital? 3. Was sequential neurological documentation present on ER record if patient had a diagnosis of skull fracture, intracranial injury, or spinal cord injury? 4. If patient had an epidural or subdural brain hematoma, did he/she receive a craniotomy >4hrs after arrival to ER? 5. Was there a diagnosis at discharge of cervical spine injury not indicated in admission diagnosis? 6. Did the patient require a laparotomy that was not performed within 1 hr of arrival to the ER? 7. If patient sustained a gunshot wound to the abdomen was he/she managed non-operatively. 8. If patient had a femur fracture, was the operation performed >24 hrs after admission? 28

9. If the patient sustained a compound extremity fracture, was the operation performed >6 hrs after admission? 10. Was there an unplanned return to the OR within 48hrs of initial procedure? 11. Was a trauma patient admitted to hospital under other than a surgeon or intensivist? 12. Did the patient have any missed injuries that subsequently required surgery? 13. Was the Trauma Team response >10min? 14. Was the length of time at rural hospital was >2hrs? 15. Did the patient die during transport? 16. Did the patient die <24hours of admission? 17. If <200km from a trauma center, arrive at trauma center within 2.5hrs of initial EMS contact? 18. If 200-400km from a trauma center, arrive at a trauma center within 4hrs of initial EMS contact? 19. If >400km from a trauma center, arrive at a trauma center within 6hrs of initial EMS contact? 20. How long was the patient on a backboard? (minutes) 21. Did the patient meet Trauma Team Activation Criteria? 22. Was the massive transfusion protocol ordered? 23. Did the patient receive 4 or more units of packed cells in the first hour? 24. Were the pre hospital guidelines violated? 25. Was the EMS scene time greater than 20 minutes? 26. The patient left the emergency department with GCS <8 with no definitive airway. (Rural and RD ER) 27. Did the unstable patient require a laparotomy that was performed within one hour of arrival to the ER? (unstable patient: BP<90, uncontrolled bleeding, HR> 110) 28. Did the patient have a pneumothorax or hemothorax? 29. Was a chest tube inserted at the sending hospital? Filter #1-#19 are fixed questions in the trauma registry software and the Provincial Trauma System. Filter #20-#29 are specific to Central Zone Trauma Program. 29

Audit Filters YES NO UNKNOWN The time between the initial medical contact (EMS or first hospital) and the arrival at the Trauma Centre was greater than 150 minutes. If the patient had an epidural or subdural hematoma, did he/she receive a craniotomy >4 hrs after arrival to the ER? Unstable patients who waited longer than one hour after arrival to receive a laparotomy. Patients who waited longer than six hours to receive a repair of their compound fracture. Patients who waited longer than two hours at a rural hospital before being transferred to the Trauma Centre. Emergency Medical Services scene time in excess of 20 minutes. Total number of applicable patients 30 101 12 143 2 2 0 4 3 4 0 7 1 3 1 5 19 12 0 31 47 34 24 105 Patients who met trauma activation guidelines. 96 44 3 143 Occurrence of Trauma Team activation. 79 63 1 143 Trauma Team response time was greater than ten minutes. 0 0 0 79 Emergency Medical Services forms were missing. 17 99 0 133 Sequential neurological documentation on the Emergency Department form was incomplete. 19 50 0 69 There was a discharge diagnosis of a cervical spine injury that was not indicated in the admission 0 138 0 138 diagnosis. There was an unplanned return to the operating room. 0 23 0 23 The patient was admitted by a family doctor, rather than a surgeon or intensivist. 22 62 0 84 The patient had a missed injury that needed surgery. 2 138 0 140 The patient died while being transported to the hospital. 0 5 0 5 The patient died less than 24 hours after arriving at the hospital. 2 3 0 5 Massive Transfusion Protocol was initiated. 3 140 0 143 Results complied from data gathered from April 1 2012 to March 31 2013 *Of the 44 patients who did not meet TTA criteria, the Trauma Team was activated 3 times. The incidence of the Trauma Team being activated for patients who do not meet criteria is 7%. 30

PIPS Comments The delay in rural non trauma centers continues to be a concern. Of the 31 patients transferred in to the Red Deer Regional Hospital 19 were greater than 2 hours in the transferring hospital. Potential reasons: - A delay in contacting an accepting service or transfer approval by the receiving hospital. -Delay in recognizing the need for transfer. -Waiting for appropriate mode of transport delayed by busy services or weather. There has not been a shift in practice since last year. 58% of the patients transferred in to RDRHC last year were delayed in a rural non trauma center compared to 61% this year. Despite an increase in education to rural physicians and changes to the EMS dispatch for the province no improvement is noted. More communication is needed with the rural non trauma centers to track the reasons for delays in transfer to trauma centers. Trauma Activation also continues to be a concern. 96 of 143 trauma patients met trauma activation guidelines/ 44(31%) did not. Our trauma activation guidelines may need revision but will review and watch closely in the coming year. 55% of patients qualifying for trauma activation actually had the trauma team activated. Future Goals Visit two rural non trauma centers and provide education on trauma transfers. Provide feedback to rural non trauma centers Host trauma rounds at the RDRHC Initiate Aspen Collar use and education to the ER, ICU, Unit 23, Occupational Therapy at the RDRHC 31