Trauma Program Annual Report Red Deer Regional Hospital Central Zone

Trauma Program Annual Report Red Deer Regional Hospital Central Zone April 1 2010 March 31 2011 Prepared by: Brenda Wiggins Central Zone Trauma Coordinator Kyla Hoogers Central Zone Trauma Data Analyst Dr Lyle Thomas Central Zone Trauma Medical Director

Table of Contents: Introduction... Page 3 Medical Director s Message... Page 4 Mission... Page 5 Structure of the Trauma Program... Page 6 How data is collected?... Page 6 Who qualifies to be in the Registry?... Page 7 AIS/ISS explained... Page 7 Trauma Activation... Page 8 Education... Page 10 Trauma Program Accomplishments... Page10 Performance Improvement and Patient Safety... Page 11 Audit filters... Page 11 Future Goals... Page 12 Stats for the Central Zone... Page 13 Total # of trauma patients... Page 13 Direct arrivals vs. private auto... Page 14 Admitted vs. transferred to Higher Level of Care... Page 15 Destinations when transferring to a Higher Level of Care... Page 16 Pediatric trauma, admitted vs. transferred... Page 17 Types of Injuries... Page 18 Gender Breakdown... Page 19 Mechanism of Injury... Page 20 Mechanism of Injury by age... Page 21 Place of Occurrence... Page 22/23 Destination after the Emergency Department... Page 24 Sports and Recreation... Page 25 Work related Injuries... Page 26 Deaths... Page 27 2

The Central Zone Trauma Program was established January 2008, formerly the David Thompson Health Region. Funding was provided by Alberta Health and Wellness to develop a Level 3 Trauma Program at the Red Deer Regional Hospital. The Trauma Program from the Red Deer Regional Hospital began participating on The Provincial Trauma Committee in 2008 this was the beginning of the Alberta Trauma System. The Central Zone Trauma Program services approximately 445,004 (AHS, 2010) people over 95 000 square kms, both urban and rural. It is situated between Edmonton and Calgary along the QE ll highway, covering the south central portion of the Province of Alberta. 3

Trauma Medical Director s Message Having been involved since the inception of the Central Zone Trauma Program, I am truly amazed by the growth that has taken place over the last year. As our infant program grows, so should the pride of those involved in the monumental task of improving trauma care in our region and the entire province. While I am thankful to be able to participate in it s growth, nothing would be possible without the tireless work of our trauma coordinator, data analyst and the clinicians and allied health workers involved in the everyday care of our trauma patients. I am also thankful for the continuous support we receive from all our partners in both the Northern and Southern Alberta Trauma Systems. There were several highlights for the Central Zone Trauma program over the past year. Most notably was the accreditation of the Red Deer Regional Hospital (RDRH) as a Level 3 trauma center. Thanks to the support of all physician and nursing staff, administration and our partners in the Southern Alberta Trauma System, we were able to achieve this lofty goal. The exhausting but informative process of accreditation by the Trauma Association of Canada helped open our eyes to recognize the great trauma care already being provided by all health care staff within our region. More importantly though, it identified the many areas where we can continue to grow to further improve trauma care for our patients. The accreditation was not a final destination, but instead a stepping stone to see the new heights we can achieve as a trauma system. The challenge to improve has been met with great enthusiasm by the Trauma Program and we look forward to working towards new goals and ideas. As we go forward, we remain committed to certain goals that were identified at the outset of our program. Standardizing trauma care across the region is important to ensure equal quality of care to all trauma patients within our system. The creation and dissemination of treatment guidelines, use of standardized trauma assessment sheets, and the newly created EMS destination protocols will help us attain this goal. Education remains a top priority, both onsite at RDRH and at our peripheral hospitals. The success of our First Annual Central Zone Education Day has inspired us to make it an annual event to share knowledge and experiences with all our trauma partners. Quality assurance through chart reviews and analyses of our data collections and QI filters remains the corner stone to maintaining the high standard of trauma care we aspire too. Many thanks again to all those whose hard work and dedication has improved trauma care in the Central Zone over the past year. We continue to rely on your passion and support to make our next year even more successful. Dr. Lyle Thomas MD, CCFP(EM) Medical Director, Central Zone Trauma Program 4

Vision To provide outstanding trauma care. 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. 5

Structure of the Trauma Program Central Zone Medical Director Director of Emergency/Critical Care Services Nursing Medical Director of the Emergency Departments in the Central Zone Emergency Department Manager Central Zone Trauma Medical Director Central Zone Trauma Coordinator Central Zone Trauma Committee Trauma Data Analyst Trauma Secretary How data is collected? Each month a report is run from the meditech system on all the ER 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 are done if they are an ISS of >9 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. For the year of 2010/2011 339 charts were reviewed and 104 were entered into the Trauma registry. The Trauma Registry The trauma registry is a requirement for any accredited trauma center, by the Trauma Association of Canada. The trauma registry is a data based software that collects fields of information from the trauma chart. This information is entered by the Trauma Data Analyst. The information entered into the registry is pulled and used for the use of Performance Improvement and Patient Safety. 6

Who qualifies to be in the registry? Data collection started April 1 2008 with the criteria below. The Trauma Registry at the Red Deer Regional hospital has contributed to the Alberta Trauma Registry and the National Trauma Registry since April 1, 2008. There are graphs following that will reflect comparisons to these previous years. If any of the following conditions are present and the patient has an ISS (Injury Severity Score) of 12 the patient will be entered into the trauma registry Admission to the Red Deer Regional Hospital Transfer to a higher level of Care Trauma Death in the Emergency Department Patients that die at the scene are not included in the trauma registry. AIS Score How the ISS is is calculated? AIS is anatomically based and are 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

Example of ISS (Injury Severity Score) calculation: Region Injury AIS ISS Head and Neck Frontal lobe contusion 3 9 Face No injury 0 Chest Pneumothorax 3 9 Abdomen No injury Extremity Fractured radius 2 9 Fractured femur 3 Fractured pelvis 2 External Laceration to forehead 1 Total ISS 27 Trauma Activation The following are criteria at the Red Deer Regional Hospital Emergency Department for trauma activation. The triage nurse receives a telephone report from EMS, transferring hospital or the patient comes by private auto to the Emergency Department. The nurse then makes the decision to activate the trauma team based on the physical assessment and the following criteria. Vital Signs and Level of Consciousness: Anatomy 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 Crush, degloved or mangled extremity Amputation proximal to wrist and ankle Unstable pelvic fracture Open or depressed skull fracture Paralysis 8

Mechanism of Injury 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 Initially the Emergency department physician, 3 nurses, 1 respiratory therapist, lab tech and radiology tech respond to TTA (Trauma Team Activation). The emergency physician acts as the TTL (Trauma Team Leader). The services of General Surgery, Orthopedics, Plastics, Pediatrics, Anesthetists, ICU intensivist are available by phone. Any patient requiring the specialties of neurosurgery, spine surgery, and cardiovascular surgery cannot stay in Red Deer and must be transferred out. They will be stabilized and a transfer arranged. 9

Education In 2010 2011 numerous educational opportunities were made available not only to the staff at the Red Deer Regional Hospital but the rural hospitals in the Central Zone. Telehealth Opportunities were made available from the Foothills Medical Center Trauma Services Trauma Rounds. TNCC/ENPC There were five TNCC courses and 2 ENPC courses offered in the central zone by the education department. The Trauma Coordinator instructed in 3 TNCC courses for this fiscal year. Outreach education was made available to rural nurses the Trauma Coordinator travelled to Rimbey, Drayton Valley and Daysland doing Trauma Scenarios. In addition any reviewed any special educational requests and updates on the trauma system In house education In services on Spinal precautions and log rolling with the staff of the ER, ICU, DI and the Respiratory Therapist was completed. Spinal precautions and log rolling were also reviewed with new staff in the ER orientation. What did the Trauma Program accomplish in 2010/2011? Continued participation on the Provincial Trauma Committee Finalized the draft of the spinal clearance flowchart/spinal precautions policy Reviewed and accepted the completed version of the Massive Transfusion Protocol developed by the Transfusion Committee for trauma patients. Prepared and participated in accreditation of the Southern Trauma System with the Trauma Association of Canada Trained a new Trauma Data Analyst and developed an orientation for Trauma Data Analyst at the Red Deer Regional Hospital. November 2011 Red Deer Regional Hospital was accredited as a Level 3 Trauma Center by the Trauma Association of Canada. 10

Performance Improvement and Patient Safety 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. Audit filters/performance indicators assist in flagging charts for review. 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 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. The following audit filters were used in 2010/2011 to flag charts for review: Audit filters 2010/2011 1. Absence of any pre hospital ambulance reports from any phase of patient transport. 2. Absence of q30min chart documentation for patient beginning with ER, including time in radiology, up to admission to the OR, ICU, ward, death or transfer to another hospital. 2a. Absence of appropriate patient vital signs documentation (BP, P, RR, GCS, and temp.) based on patient s condition: If patient UNSTABLE vitals<or =q5min If patient is STABLE vitals q15min x4, q30min x2 and q1hr thereafter. If temperature<34, minimum temperature q 30 min 3. Absence of sequential neurological documentation on ER record if patient had a diagnosis of skull fracture, intracranial injury, or spinal cord injury. 3a. Absence of sequential neurologic documentation (GCS and Pupils) If GCS>=14 q1hr x4 then decrease If GCS11 13 q1hr If GCS <11 at min.q1hr as needed 4. Patient with epidural or acute subdural with transfer delay > 4hrs 5. Patient with diagnosis at discharge of cervical spine injury not indicated in admission diagnosis. 6. Did the unstable patient require a laparotomy that was not performed within 1hr of arrival to the ER? 11

7. Patient sustained a gunshot wound to the abdomen who was managed non operatively. 8. Patient with a femur fracture that was operated on >24hrs after admission. 9. If the patient sustained a compound extremity fracture, was the operation performed >6hrs after admission? 10. Was there an unplanned return to the OR within 48hrs of initial procedure? 11. Trauma patient admitted to hospital under other than a surgeon or intensivist. 12. Patient had missed injuries that subsequently required surgery. 12. Any injury not diagnosed with 24 hrs of entry to RDRH. 13. Was the trauma team called? 13a. Did the team response exceed >10min 14. Length of time at rural hospital was >2hrs? 14a. If <200km from a trauma center, arrive at trauma center within 2.5hrs of initial EMS contact? 14b. If 200 400km from a trauma center, arrive at a trauma center within 4hrs of initial EMS contact? 14c. If >400km from a trauma center, arrive at a trauma center within 6hrs of initial EMS contact? 15. Patient died during transport. 16. Patient died <24hrs of admission. Future goals For the year 2011 2012 we would like to continue with the education within the Red Deer Regional Hospital including the Emergency Department, Intensive Care and Unit 23. Provide the staff with practice guidelines specific to their area of practice. Increase the number of trips to the rural hospitals to provide trauma education opportunities to both Physicians and Nursing. Co hort trauma patients on to a single surgical unit. Continue working on a relationship with the Central Zone Injury prevention program and become more involved with injury prevention Make more Telehealth educational opportunities available to the staff at RDRHC. Evaluate and make changes to the Performance Improvement and Patient Safety including have Morbidity and Mortality rounds. Reevaluate the Trauma Activation guidelines 12

How many Major Trauma Patients were seen at Red Deer Regional Hospital? The total number of trauma patients seen in the RDRHC emergency department in 2010 2011 with an ISS of 12. Admitted, transferred or Died in the ER were 104. The 3 year trend graph shows a 22% increase in trauma patients with and ISS of 12 from 2009/2010 to 2010/2011, a 17% increase from 2008/2009 to 2009/2010 There were 1064 Minor and Major trauma admissions, transfers, or deaths to RDRH (regardless of the ISS) for 2010 2011 120 TOTAL NUMBER OF PATIENTS INJURY SEVERITY SCORE > 12 2008-2011 100 NUMBER OF PATIENTS 80 60 40 67 81 104 20 0 2008/2009 2009/2010 2010/2011 YEARS 13

The arrivals by ambulance vs the arrivals by private auto did not significantly change over the past 3 years: In 2010/2011 78% of arrivals to RDRHC ER arrived by ambulance, 22% arrived by private auto In 2009/2010 82% of arrivals to RDRHC ER arrived by ambulance, 18% arrived by private auto In 2008/2009 86% of arrivals to RDRHC ER arrived by ambulance, 14% arrived by private auto 14

ADMITTED VS. TRANFERRED TO A HIGHER LEVEL OF CARE ISS 12 2008 TO 2011 70 60 50 NUMBER OF PATIENTS 40 30 20 31 44 36 35 59 45 ADMITTED TO RDRHC TRANSFERRED TO HIGHER LEVEL OF CARE 10 0 2008/2009 2009/2010 2010/2011 YEARS Transfers to higher level of care 2010/2011 57%admitted to RDRHC 43% transferred to higher level of care Transfers to higher level of care 2009/2010 54% admitted 43% transferred Transferred to higher level of care 2008/2009 46% admitted 54% transferred Through the past 2 years the number transferred vs admitted has stayed virtually unchanged. The first year of data collection there were slightly less major traumas admitted to RDRHC. 15

Destinations When Transferred to a Higher Level of Care ALBERTA CHILDREN'S HOSPITAL 3% (2) 2010/2011 STOLLERY CHILDREN'S HOSPITAL 3% (2) ROYAL ALEXANDRA HOSPITAL 5% (3) UNIVERSITY OF ALBERTA HOSPITAL 26% (17) FOOTHILLS MEDICAL CENTRE 63% (41) ALBERTA CHILDREN'S HOSPITAL FOOTHILLS MEDICAL CENTRE ROYAL ALEXANDRA HOSPITAL STOLLERY CHILDREN'S HOSPITAL UNIVERSITY OF ALBERTA HOSPITAL When transferring to a higher level of care the Red Deer Regional Hospital will to any of the following Trauma Centers; including University of Alberta Hospitals, Stollery Children s hospital, Royal Alexandra Hospital, Foothills Medical Center and the Alberta Children s hospital. The decision to go to Edmonton or Calgary is always made on a case to case basis. It is made according to patient wishes and resources available to best serve the patient s condition. It was always thought that 50% went to Edmonton and 50% went to Calgary but for 2010/2011 but for the adult trauma population 63% went to the Foothills Medical Center and 26% to the University of Alberta/5% to the Royal Alexandra Hospital. The Pediatric Trauma patients were evenly split between Stollery and Albert Children s Hospital at 3%. 16

Pediatric Trauma The number of major pediatric patients (ISS 12) seen at Red Deer Regional Hospital has remained constant over the past 3 years. Many pediatric traumas have been seen and admitted to RDRHC but only 10 pediatric trauma patients were an ISS 12. A total of 5 pediatric trauma patients were transferred out and 4 of those were sent to Stollery and Alberta Children s, the 5 th patient went to the Foothills Medical Center. PEDIATRIC PATIENTS ADMITTED VS. TRANSFERRED INJURY SEVERITY SCORE 12 2008 TO 2011 8 8 7 6 5 4 3 2 3 4 3 5 5 ADMITTED TRANSFERRED 1 0 2008/2009 2009/2010 2010/2011 17

TYPES OF INJURIES ISS 12 2010/2011 OTHER 1% (1) PENETRATING 6% (6) BURNS 3% (3) BLUNT PENETRATING BURNS OTHER BLUNT 90% (94) Blunt injuries continue to be the leading cause of injury with 90% of the total major trauma seen at RDRHC. 6% of patients were penetrating injuries and 3% burns. The other category is a hanging. The Penetrating injuries are much higher in the Red Deer hospital than the numbers show. Many are not seriously injured and can be discharged home, but the limitations of the AIS/ISS scoring does not capture the majority of admitted penetrating injuries falling between ISS of 9 and 12. 18

GENDER BREAKDOWN INJURY SEVERITY SCORE > 12 2010/2011 29 28 NUMBER OF PATIENTS 7 3 5 6 8 5 7 6 MALE FEMALE AGES NEWBORN TO 16 AGES 17 TO 34 AGES 35 TO 52 AGES 53 TO 70 AGES 71 AND OLDER The males between 17 and 52 were the highest number of major traumas seen at the Red Deer Regional Hospital Overall 68% of major traumas (ISS 12) were males and 32% females. 45% of the major trauma was between the age of 17 and 52 and male 19

MECHANISM OF INJURY ISS 12 2010/2011 OTHER 15% (16) FALLS 26% (27) ASSAULTS 11% (11) NON MOTOR VEHICLE COLLISIONS 10% (10) FALLS MOTOR VEHICLE COLLISIONS NON MOTOR VEHICLE COLLISIONS ASSAULTS OTHER MOTOR VEHICLE COLLISIONS 38% (40) The three leading mechanisms of injury for major trauma (ISS 12) in the Central Zone were; Motor Vehicle Collisions (38%, n=40), Falls (26%, n=27) and Assaults (11%, n=11) The Other injuries include burns, hangings, chemical injury and drownings. Most of the falls that qualify are not ground level falls, ground level falls are usually hip fracture and do not qualify for the Alberta Trauma Registry and the National Trauma Registry (ISS 12). 20

NUMBER OF PATIENTS MECHANISM OF INJURY BY AGE RANGE INJURY SEVERITY SCORE > 12 2010/2011 16 14 12 10 8 6 4 2 0 < 15 15 24 25 34 35 44 45 54 55 64 65 74 75 84 85 + Transportation 4 15 5 6 10 5 3 3 0 Falls 1 2 3 3 5 1 3 7 2 Assaults 0 3 2 3 1 0 0 0 0 Burns 2 0 0 1 0 0 0 0 0 Suicide/Self harm 0 0 1 0 0 0 0 0 0 Other 1 1 4 4 2 0 1 0 0 Transportation injuries for the ages of 15 45 were mostly Motor Vehicle Collisions, there were some Motorcycle crashes and horse related injuries. After 65 years, Falls dominated the major mechanism of injury with Transportation coming in second. 21

4% n = 34 n = 2 5% n = 5 PLACE OF OCCURRENCE OF TRAUMA INJURY SEVERITY SCORE OF 12 OR HIGHER 2% 5% n = 5 32% n = 4 5% n = 5 2010/2011 26% n = 27 21% n = 22 HOME STREET/HIGHWAY SCHOOL/PUBLIC INSTITUTION/ATHLETIC AREA TRADE/SERVICE AREA INDUSTRIAL/CONSTRUCTION AREA FARM OTHER UNKNOWN 22

Place of Occurrence 32% of injuries occurred in the street/highway, 21% occurred in the home. The large number of unknown is due to the lack of documentation on the walk ins. Of the injuries from the streets the largest numbers (91%) come from Motor Vehicle collisions. Injuries at home are lead by falls at 50% 23

OTHER 2% (2) DIED 2% (2) DESTINATION AFTER EMERGENCY DEPARTMENT VISIT INJURY SEVERITY SCORE 12 2010/2011 ICU ADMISSION 3% (3) OPERATING ROOM 10% (10) SURGICAL WARD ADMISSION 43% (45) TRANSFER OUT 40% (42) TRANSFER OUT SURGICAL WARD ADMISSION ICU ADMISSION OPERATING ROOM DIED OTHER Following resuscitation 40% of the major trauma patients were transferred to a higher level of care. 43% will be admitted to a surgical ward, 10% to the OR, 3% to ICU, 2% died Other would include palliative or medical unit. Pediatric patients were included in these totals. 24

TRAUMA RESULTING FROM SPORTS OR RECREATION ACTIVITIES INJURY SEVERITY SCORE > 12 2010/2011 8 8 NUMBER OF PATIENTS 7 6 5 4 3 2 1 0 5 2 1 2 1 4 1 1 ATV/DIRTBIKES BICYCLES HORSE RELATED ICE HOCKEY SKATEBOARDING SKIING SNOWMOBILING WATERSPORTS OTHER In Central Alberta, the highest number of recreational injuries was related to recreational horse use at 32%. These have all been recreational injuries if there was a situation that a horse is being used for farm work it is documented in work related injuries. At 20 % we have ATV/dirt bike injuries followed closely by snowmobile injuries at 16%. 25

WORK RELATED INJURIES INJURY SEVERITY SCORE 12 2010/2011 FARM 3% (3) CONSTRUCTION/ INDUSTRIAL 5% (5) FARM CONSTRUCTION/INDUSTRIAL NON WORK RELATED NON WORK RELATED 92% (96) The Central Zone is a large farming community and a home to many oil industry businesses. In 2010/2011 there was only 3 % of the total major trauma that were attributed to farming injuries. The City of Red Deer continued to have an increase in the population for 2010\2011. This in turn means construction and a large industrial population with the oil industry grew. Construction and industrial injuries totaled 5 % of the major traumatic injuries seen at the Red Deer Regional Hospital. 26

4.5 4 4 DEATHS DUE TO TRAUMA INJURY SEVERITY SCORE 12 2010/2011 3.5 3 3 3 2.5 2 2 2 2 2008/2009 2009/2010 1.5 2010/2011 1 1 1 1 0.5 0 DIED IN EMERGENCY DIED < 24 HOURS AFTER ADMISSION DIED > 24 HOURS AFTER ADMISSION 3 of the 5 deaths were trauma patients that had CPR/ATLS started at the scene and continued upon arrival to the Emergency Department. 3/5 deaths mechanism of injury were falls. 2 deaths were palliative, the injuries were severe and the wishes of the patient and the family were to provide comfort but no intubation. 27