Trauma Program Annual Report AHS: South Zone West (Lethbridge)

Trauma Program Annual Report AHS: South Zone West (Lethbridge) 2008-2010 Provided by: Theresa Pasquotti, Trauma Coordinator Cindy St. Dennis, Trauma Data Analyst Dr. Kevin Martin, Trauma Medical Director Table of Contents: 1. Introduction 2. Clinical Care 3. Education 4. Quality Assurance 5. Future Planning 6. Trauma Statistics

1. Introduction The Trauma Program for the South Zone West (former Chinook Health Region) was established in October 2008. At that time, the province of Alberta provided funding to regional centres across the province to develop as Level 3 Trauma Centres. South Zone West serves approximately 160,000 residents most of which live in the city of Lethbridge. The western portion of the zone covers 25,947 km 2 in the south western corner of southern Alberta. The mission of the Southwest Zone trauma program is to develop and maintain a comprehensive trauma system for the prevention, treatment, and rehabilitation of injury focusing on the individual, family, and community. To get the injured person to the right treatment at the right trauma facility in the shortest time. Over the past 2 years, the Trauma Program has funded part-time positions for a Trauma Medical Director, Dr. Kevin Martin; a Trauma Coordinator, Theresa Pasquotti; and a Data Analyst, Cindy St. Dennis. One of the primary goals of the program was to attain Level 3 Trauma Accreditation through the Trauma Association of Canada (TAC). The southern region of Alberta went through the Accreditation Process November 15-17, 2010

with Foothills Medical Centre Trauma Services as the lead agency. We are very pleased and proud to have received Level 3 Centre Accreditation through TAC. Although the program is relatively new, we have collected 2 fiscal years worth of trauma data. Patient data is collected on all trauma patients including adults and children, within the South Zone West area including the Regional Referral Centre: the Chinook Regional Hospital and the rural centres of: Cardston, Crowsnest Pass, Fort Macleod, Milk River, Pincher Creek, Raymond, and Taber. Patients are entered into the Trauma Registry if their Injury Severity Score (ISS) is greater than or equal (>) 12 and if they are admitted or transferred or die in the emergency department. Patients who die at the scene of their traumatic event are not represented in this report. Injury Severity Score (ISS) is an anatomical scoring system that provides an overall score for patients with multiple injuries. Each injury is assigned an Abbreviated Injury Scale (AIS) score and is allocated to one of six body regions (Head, Face, Chest, Abdomen, Extremities (including Pelvis), External). Only the highest AIS score in each body region is used. The 3 most severely injured body regions have their score squared and added together to produce the ISS score. It is a summary score to characterize the multiple injuries typically sustained by the trauma patient. The ISS ranges from 12-75 with the assumption that the higher the score, the more serious the injury. The ISS is captured in the Lethbridge trauma registry and submitted to the Alberta Trauma Registry which submits to the National Trauma Registry. This report will combine both the 2008-09 & 2009-10 fiscal years data. The Chinook Regional Hospital Emergency Department sees over 46,000 patients annually and receives over 500 ambulance visits every month. Whether the patient arrives by ambulance direct from the scene or is transferred from a rural site, the patient is received in the emergency department by a skilled group of professionals. When the Trauma Team is activated it consists of: a Trauma Team Leader (TTL) Emergency Physician and trauma Registered Nurses (RN s), General Surgery, Anaesthesia, Radiologist, Medical Imaging technician, a Registered Respiratory Therapist (RRT), Laboratory assistant, and CT technician. If the patient is less than 12 years of age, a Pediatrician will be called. If an Orthopedic Surgeon is requested, they will be called in as well. In addition, the on-call chaplain is called; housekeeping, security, and porters will respond to the ED for support. The Chinook Regional Hospital is able to care for a number of injured patients including those requiring general surgery and orthopedic surgery. We can admit most orthopedic trauma, including bone and articular fractures. We will transfer any spine or pelvis fractures that require operative interventions to Level 1 Centre in Calgary. Some pediatric injuries will go to the Alberta Children s Hospital as well. The general surgeons will manage most abdominal injuries including liver,

splenic, and bowel injuries. Patients requiring brain, spinal or vascular intervention would be stabilized in Lethbridge and then sent to Calgary. However, we might keep brain injured patients not requiring surgery after consultation with the Neuro surgeon at the Level I centre. At the Lethbridge site, we have urology, opthalmology, and plastic surgery coverage much of the time. We wish to thank all of the staff at the Chinook Regional Hospital and our rural partners who have had an impact on the Trauma Program and continue to support our goals in caring for critically injured adults and children. We also want to thank the Foothills Medical Center Trauma Program, Alberta Children s Hospital Trauma Program, and the University of Alberta/Stollery Trauma Programs for their leadership and support for the development of our trauma program.

2. Clinical Care The South Zone West Trauma Program has been identifying ways to improve the clinical care of the trauma patient. Over the past 2 years the following activities have taken place: i) Development of the CRH Site Trauma Committee ii) Revision of Trauma Team Activation (TTA) Criteria and guidelines iii) Revised the Trauma Documentation for Nursing and Emergency Physician iv) Revised Trauma Bloodwork Set v) Development of the following guidelines/policies: C-spine assessment algorithm Pelvic Splinting policy Massive Transfusion Protocol (MTP) Adult C-spine Assessment algorithm Trauma Admission Policy vi) 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 - Members

3. Education As a Trauma Program, we have provided a number of Educational opportunities for a variety of staff (nurses and physicians) throughout the zone. i) Rural Outreach: Dr. Martin and Theresa Pasquotti went to six of the rural sites to provide an overview of trauma care and skill review to the rural physicians in 2010. Sites included: Pincher Creek, Cardston, Taber, Crowsnest Pass, Fort Macleod, and Raymond. This was well received and will continue to provide annually. ii) TNCC: Trauma Nursing Core Course is offered twice a year for the nurses throughout the south zone. This course is well received by nursing staff. iii) Simulation: We have started utilizing the simulation lab at the Lethbridge College to provide some trauma education annually. The Alberta Children s Hospital Simulation program has come to Lethbridge annually to provide 2 days of simulation sessions which includes trauma. iv) Telehealth FHMC Grand Rounds: When the Foothills Medical Center presents trauma grand rounds on a monthly basis, we participate in the video conferencing at the CRH site. v) Emergency Nursing Competency Days: The CRH ED nurses have a monthly competency day in which the Trauma Coordinator provides 2 hours of trauma education. The Emergency/Critical Care Educators provide some trauma education to the ICU nurses on their monthly competency days.

4. Quality Assurance One of the goals of the trauma program is to provide a continuous performance improvement and patient safety (PIPS) process. The objectives of this process include: - To provide a mechanism for peer review, oversight, and evaluation of all aspects of trauma care. - To utilize outcome measures to assist in ensuring the provision of quality care and service to trauma patients, their families, referring providers and medical centres in the zone. - To assess and improve patient care processes and organizational functions of trauma care within the system. To accomplish this, charts are reviewed and abstracted by our Data Analyst and data is entered into the registry. 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, the Alberta Trauma Registry, and audit filters used by Foothills Medical Center and Alberta Children s Hospital. All cases are reviewed by the Trauma Coordinator. The Trauma Medical Director reviews a number of cases that are flagged by the audit filters. The Trauma Program will send out letters of feedback to various providers in the system. There have been trauma cases which have been reviewed under the Emergency Department Quality Assurance Committee. With the changes to AHS, any trauma case that the trauma program recommends a quality assurance review be done will be presented to the Director of the Emergency/Critical Care/Medical/Subacute Program for review by the CRH site QA committee. The CRH performance indicators and audit filter questions for 2009-10 are summarized below. ACS Audit Filters: 1. Are all prehospital ambulance reports from all phases of patient transport present on the medical record? 2. Was q30 minute chart documentation present on 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 the patient had an epidural or subdural brain hematoma, did he/she receive a craniotomy > 4 hours after arrival to ER? 5. Was there a diagnosis at discharge of cervical spine injury not indicated in admission diagnosis? 6. Did patient require a laparotomy that was not performed within 1 hour of arrival to 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 hours after admission? 9. If the patient sustained a compound fracture, was the operation performed > 6 hours after admission? 10. Was there an unplanned return to OR within 48 hours 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. Did the trauma team response time exceed 10 minutes? 14. Was the length of time at a rural hospital > 2 hours? 15. Did the patient die during transport? 16. Did the patient die < 24 hours of admission? CRH performance indicators/elements: 1. If the distance was < 200 km, was total transport time from scene-sending hospital to the trauma center >3 hrs? 2. If the distance was 200-400 kms, was total transport time from scene/sending hospital to the trauma center >4 hrs? 3. If the distance was > 400 km, was total transport time from scene-sending hospital to the trauma center >6 hrs? 4. Did the patient with a first recorded scene GCS 8 receive an airway as an intervention at the scene? 5. Did the patient with a first recorded trauma centre GCS < 8 receive a mechanical airway as an intervention in the ED? 6. Was the patient assigned a Triage code 4 or 5? 7. Was the Massive Transfusion Protocol initiated on this pt? 8. For patients with an ischemic (i.e., pulseless) limb(s) secondary to severe fractures or penetrating arterial trauma, was the limb(s) revascularized (via fracture reduction, or an OR visit for repair, shunt or graft) within 6 hours of injury or transferred to higher level of care within 2 hours? 9. Did the patient receive operative management of major facial fracture(s) (mandible, maxilla or orbit) at the trauma centre, within 7 days of the injury? 10. How many units of red blood cells (RBCs) did the patient receive in the first hour after the injury or until death (if the patient died within the first hour)? Include all RBC given during transport, at sending hospital and at the trauma centre. 11. How many units of red blood cells (RBCs) did the patient receive in the first 24 hours after the injury or until death (if the patient died within 24 hours)? Include all RBC given during transport, at sending hospital and at the trauma centre.

12. If the patient had a dislocated hip, shoulder, knee, and/or elbow, was there an attempt to reduce it (them) within 1 hour of arrival to the trauma centre? 13. For the patient with a trauma centre GCS < 13or intubated at the time the trauma centre GCS was calculated and had a CT of the head, what was the date the initial CT was completed? 14. For the patient with a trauma centre GCS < 13or intubated at the time the trauma centre GCS was calculated and had a CT of the head, what was the time the initial CT was completed? 15. If TTA criteria met, was TTA activated? 16. If the patient sustained a pelvic ring fracture and was hemodynamically unstable in the ED, was pelvic splinting done? 17. If the patient sustained a pelvic ring fracture and was hemodynamically unstable in the ED, was an external fixator applied prior to transport to a higher level of care? 18. If the patient sustained a pelvic ring fracture and was hemodynamically unstable in the ED, was pelvic artery embolizations done prior to transport to a higher level of care? 19. If TT no activated was GS consulted at anytime during the patient s stay at the trauma centre? (TT= Trauma Team; GS=General Surgeon) 20. Was the GS arrival to the ED > 20 minutes when the TTA? 21. Were any of the Trauma Team Activation criteria met at ANY point during the patients stay at the Trauma Centre? 22. Did the trauma patient have a laparotomy? 23. If a laparotomy was done, was it performed > 2 hours of arrival to trauma centre? 24. How many units of fresh frozen plasma (FFPs) did the patient receive in the first hour after the injury or until death (if the patient died within the first hour)? Include all FFP given during transport, at sending hospital and at the trauma centre. 25. How many units of fresh frozen plasma (FFPs) did the patient receive in the first 24 hours after the injury or until death (if the patient died within 24 hours)? Include all FFP given during transport, at sending hospital and at the trauma centre.

5. Future Planning The 2010-11 year will continue the work that we have started, with a focus on Performance Improvement and Patient Safety and Education. Our focus will be on the following activities: i. Continuing to focus on Trauma Education expanding to the ICU and Inpatient areas and expanding trauma simulation experiences ii. Pursuing the feasibility of providing an annual ATLS course in Lethbridge iii. Continue regular TNCC courses twice yearly at CRH iv. Continue Rural Outreach to all of the South West Zone sites annually v. Continue to refine and improve our quality improvement activities including rounds with the Surgeons (1-2 times per year) vi. Develop additional guidelines/protocols/policies for trauma care including Standard Trauma Orders, RSI, Burn Care, Open fracture Management, and others vii. Developing good clinical documentation tools for trauma care providers (including GS, Orthopedics, Anesthesia, and Pediatrics) viii. Establishing and growing connections with other Canadian trauma programs to work collaboratively on research, quality assurance projects and improving standards of care for trauma patients ix. Establish and link with the Injury Prevention network to develop and collaborate on Injury Prevention projects

Trauma Statistics Data from April 2008-March 2010 The following is data collected into the CRH Trauma Registry from April 2008- March 2010. There were a total of 206 patients entered into the registry for the 2 fiscal years. This includes all major trauma patients with an Injury Severity Score (ISS) > 12. The following depicts how these patients are injured. Types of Injuries by ISS Ranges 100 90 80 70 60 50 40 30 20 10 0 12-16 17-25 26-35 36-45 46-55 Blunt 78 87 15 5 1 Penetrating 4 9 0 0 0 Burn 0 1 1 0 0 Other 1 1 3 0 0 The majority of patients had an ISS between 12-25 (88%). Types of Injuries What injuries did these patients sustain? To better understand the type of injuries major trauma patients sustain, they are broken down into four categories: Blunt, Penetrating, Burn and Other. Blunt injuries are the leading type of injury in major trauma patients at CRH (91%). An example of Other would include strangulation or CO poisoning. Type of Injury Penetrating, 13 Burns, 3 Other, 3 Blunt, 187

How did these injuries occur? Mechanism of Injury (MOI) has been divided into 6 categories: Transportation, Falls, Assault, Fire/Explosion, Suicide and Other. Definitions of each will be provided on the following pages. M ECHANISM OF INJURY 26 44 17 TRANSPORTATION 75 80 FALLS ASSAULT FIRE / EXPLOSION SUICIDE OTHER Of the 206 major trauma patients seen at CRH, 39% were injured due to a transportation related injury and 36 % were due to a fall related injury. Transportation and falling are the most prevalent cause of trauma related injury. Transportation Injuries: This MOI refers to trauma caused by any form of transportation, with the exception of animal transport. The following chart breaks down transportation injuries by mode. Transportation Injuries CYCLIST 1 AIRCRAFT FARM EQUIP PEDESTRIAN OFF - ROAD MVC 2 3 5 14 55 0 10 20 30 40 50 60 Transportation: Mortality: 6.25% 5 pt s died Transfers: 42 ISS range: 12-50 Mean ISS: 20 Median ISS: 18 Special Note of Interest: Out of these 80 patients, 45 of them had an ETOH documented. 14 (31.1%) had an ETOH blood level higher than 17.4 mmol/l.

Falls This MOI category refers to both multi-level and ground-level falls. Other and unspecified refers to cases where the type of fall was not documented. A multi-level fall is defined as a fall from one level to another. Of the 75 major traumas associated to falls and their documented type, 47% were due to multi-level falls. Likely, the number of ground level falls is substantially higher, but many of these patients do not qualify for the registry. For example: Single system hip fractures do not have an ISS score of 12 or greater to be included in the Trauma Registry. Types of Falls 35 30 25 20 15 10 5 0 35 M ul t i - Le v e l S a me - Le v e l Ot he r & 12% 25 15 U nspe c i f i e d Falls: Mortality: (16.2%) 12 pt s died Transfers: 33 ISS range: 14 41 Mean ISS: 22 Median ISS: 20.5 Assaults An Assault as a cause of injury is categorized as an Unarmed Brawl, Assault with an Object or Unknown/Other type of Assault. There was a total of 26 Assaults with the majority of them being the result of a knife/sharp or blunt object. Limitations of the ISS scoring system in evaluating penetrating injuries that involve single system or organ injuries likely leads to an under representation of violence. Assaults 32% 56% Assault with an Object Unarmed Assault Unk/Other Type of Assault Assault Mortality: (3.8%) 1 death Transfers: 8 ISS range: 13-35 Mean ISS: 17 Median ISS: 16.5

Other: All Other MOI has been categorized to Animal, Mechanical Suicide and Fire/Explosion. There were 24 cases in total for these categories with animal related injuries being the highest out of all 4 categories. One consideration is that an animal can not be included as a part of our transportation category (i.e.: horseback riding). Mechanical can be being struck by an object or accidentally striking against an object. Other MOI 12 10 8 6 11 4 2 5 4 4 0 Animal Mechanical Suicide Fire/Explosion Other MOI: Mortality: (17%) 4 deaths Transfers: 9 ISS range: 13-34 Mean ISS: 20 Median ISS: 17

MOI by Place of Occurrence This is a breakdown of where traumas occurred. It is useful to look at the place of injury to increase awareness for injury prevention activities and to get a more comprehensive understanding of major trauma patients. 4% 3% 7% 28% Home 7% Farm Residential Institution 7% Street/Highway Trade/Service Area Sports/Atheletics Area 5% Industrial/Construction Other Specified 4% Unspecified 35% The majority of traumas occurred on the street (35%) and then at home (28%). How many of these injuries were work related? Data is abstracted based on whether on not these injuries occurred at work. Whether it is farm, industrial, trade/service related or non-work related. Of the entire major trauma patient s only 16% were considered workplace injuries. WORK RELATED INJURIES VS NON - WORK RELATED 4% 7% 5% INDUSTRIAL TRADE/SERVICE FARM 84% NON-WORK RELATED

MOI by Age Range To better understand the relationship between MOI and age, the following chart has been included to demonstrate the proportion of MOI in each age range. Mechanism of Injury by Age Range 30 25 20 15 10 5 0 <15 15-24 25-34 35-44 45-54 55-64 65-74 75-84 85+ Transportation 3 24 12 9 9 9 3 8 3 Falls 1 4 8 4 8 7 9 18 16 Assault 0 8 4 9 3 2 0 0 0 Fire/Explosion 1 1 0 1 0 0 1 0 0 Suicide 0 2 0 0 1 0 0 1 0 Other 1 3 2 2 5 2 1 1 0 The age range that had the highest number of transportation related injuries was 15-24 yr olds. When taking these into consideration these also include off road motor vehicles such as motocross bikes and ATV. Assault injuries were the highest amongst 35-44 year olds and then 15-24 yr olds. Recreational / Sport Injuries Cliff Jumping Rock Climbing Cycle Baseball Rollerblading Snowboard Snowmobile Horseback Riding ATV Motocross Horseback riding had the highest number of injuries and then Motocross/ Dirt biking and ATV accidents. 0 1 2 3 4 5 6 7 8

Mode of Arrival The Mode of Arrival is the way the patient first presented to hospital. There are three different modes of arrival being EMS, private vehicle and walk-in. M o de o f A rrival 18 % 3 % EM S Private vehicle W alk- in 79 % The highest mode of arrival is by ambulance at 79%. The graph below will show how many of those patients arrived from one of our rural facilities on transfer to CRH. Transfers There are 7 rural facilities that transfer trauma patients to CRH for care. The facilities include Taber, Pincher Creek, Milk River, Cardston, Raymond, Fort Macleod and the Crowsnest Pass. A total of 28% of our patient s were transfers. Rural Transfers to CRH 16 15 7 6 5 4 4 Taber Cardston Raymond Pincher Creek Crowsnest Pass Milk River Fort Macleod Taber s facility had the highest amount of transfers to us with 16, and then Cardston with 15. There were 57 transfers to the CRH facility for fiscal years 2008-2010.

Head Injuries A number of trauma patients present with a severe head injury especially if they have fallen or were in an MVC (Motor Vehicle Crash). Head Injuries 7% 8% 5% 22% 8% 6% 44% Subdural Hematoma Epidural Hematoma Diffuse Brain Injury Focal Brain Injury Subarachnoid Hemorrhage Cerebral Edema Other Intracranial Injury This graph represents trauma patients that have been seen with a severe head injury. The majority of our head injuries seen are diagnosed with a subdural hematoma (SDH). Dependant on the patient s age and the severity of their injuries, the patient can either be transferred to a higher level of care, deemed palliative, or die as the result of their injuries. Head Injury Outcomes for the fiscal year 2009-10: Head injury Outcomes 2009-10 Number of patients 21 20 Transfers Outcome Admitted There were 41 patients from Apr09-Mar10 that qualified for the trauma registry. 21 patients were transferred to Calgary with one transferred back to the CRH for palliative care for a non-surgical bleed. 20 patients were admitted; 8 of them were Comfort Care/ Palliative and 12 were discharged home or back to their institutional residence.

Post Emergency Destination Where did the patient go following their arrival to CRH Trauma Center Emergency Department? The patient could either be transferred to a higher level of care, admitted to the Ward, OR, ICU or die as a result of their injury before being admitted or transferred. Post ED Destination 7% 2% 13% 41% Ward Transfers ICU OR Deaths 37% The majority of patient s were admitted to the ward (41%) and 37% of patients were transferred to a higher level care because of their injuries. Length of Stay at Rural Hospital Greater than 2Hrs 119 patients were seen in a rural facility before they were transferred to CRH or to a higher level of care. In 2008/2009, 35% stayed at a rural facility >2hrs before they were transferred. In 2009/2010, 26% stayed at a rural facility > 2hrs before they were transferred. Was the Length of Stay at a Rural Hospital >2 hours? 42 31 19 27 2008/2009 2009/2010 YES NO

Trauma Team Activations: This chart shows the number of TTA s in every month for the two fiscal yrs. Trauam Team Activations 3 Number of TTA's 2 1 1 1 2 2 1 1 1 1 1 2 1 1 1 2008-09 2009-10 0 0 0 0 0 0 0 0 Apr May June July August Sept Oct Nov Dec Jan Feb Mar Month There were 3 times in 2009-10 that the trauma team was activated for 2 or more patients. And these were counted as one TTA. Patients who are admitted to CRH: A filter question that is asked: are trauma patients being admitted to a physician other than a General Surgeon or Intensivist? We do know that some of the palliative head injury patients may be admitted to the family physician. 65 Admission to CRH Number of patients 15 23 35 Admit to FD Admit to Surgeon/IM 2008-09 2009-10 Year

Trauma Deaths: A review of all trauma related deaths are done. For the fiscal year 2008-09, the CRH site had 12 deaths and 10 deaths in 2009-10. Deaths at the rural emergency departments combined for 2008-09 were 7 deaths and 2 deaths in 2009-10. Trauma Deaths 2008-09 & 2009-10 7 Number of deaths 4 4 4 4 1 5 2 2008-09 2009-10 CRH died in ER CRH died in ICU CRH died on ward Death Location Rural ER deaths 2009-10 Deaths at CRH Site 10 9 9 8 Number of patients 7 6 5 4 3 2 1 0 Expected Deaths 1 Unexpected Deaths