ANNUAL REPORT. April 1, March 31, 2006

Transcription

1 Regional Trauma Services ANNUAL REPORT April 1, March 31, 2006 Revised June 2007

2 Regional Trauma Services ANNUAL REPORT April 1, March 31, 2006

3 Calgary Health Region Annual Regional Trauma Services Report Table of Contents Organization Structure... i Vision, Mission, Values, Roles... ii Medical Director s Message... iii Executive Summary... 1 Regional Trauma Services Activities Regional Paediatric Trauma Report Major Trauma Statistics & Outcome Data: Foothills Medical Centre and Alberta Children s Hospital Trauma Statistics: Peter Lougheed Centre and Rockyview General Hospital Regional Trauma & Injury Statistics Summaries Performance Indicators: Foothills Medical Centre Performance Indicators: Alberta Children s Hospital City of Calgary Emergency Medical Services (EMS) Annual Report Shock Trauma Air Rescue Society (STARS) Report Office of the Chief Medical Examiner Report Regional Department of Emergency Medicine Report P.A.R.T.Y. Program Report Calgary Firefighters Burn Treatment Centre Report Tertiary Neurorehabilitation Program Reports Traumatic Brain Injury Population Traumatic Spinal Cord Injury Population Profile of Injuries in the Calgary Health Region Report Appendices Appendix A: Trauma Research Publications Appendix B: Trauma Research Funding Summary

4 ORGANIZATIONAL STRUCTURE (April 1 st /2005-March 31 st /2006) Regional Trauma Services personnel include: Southwest Community Portfolio/Regional Trauma Services: Ms. Tracey Wasylak, Vice President, Southwest Community Portfolio Dr. Robert Abernethy, Executive Medical Director, Southwest Community Portfolio Ms. Marg Semel, Director, Inpatient Surgical Services & Trauma Services Dr. Robert Mulloy, Interim Regional Trauma Services Medical Director (Nov/2004-Nov/2005) Ms. Dianne Dyer, Regional Trauma Services Manager Ms. Stacey Litvinchuk, Regional Adult Clinical Nurse Specialist Ms. Joanne Bouma, Regional Adult Clinical Nurse Specialist Mr. Laurie Leckie, Regional Paediatric Trauma Coordinator Ms. Christi Findlay, Regional Trauma Services Data Analyst Ms. Maria Vivas, Regional Trauma Services Data Analyst Ms. Sukhi Lally, Regional Trauma Services Data Analyst Ms. Monica Rodriguez-Galvez, Regional Trauma Services Administrative Assistant Child & Women s Health Portfolio: Alberta Children s Hospital Site (ACH): Ms. Brenda Fischer, Vice President, Child & Women s Health Dr. Brian Stewart, Executive Medical Director, Child & Women s Health Ms. Toni MacDonald, Director, Child Health Programs, Child & Women s Health Dr. Francois Belanger, Interim ACH Trauma Director Mr. Laurie Leckie, Regional Paediatric Trauma Coordinator Ms. Maria Vivas, Regional Trauma Services Data Analyst Adult Trauma Committee Chairpersons: Dr. Robert Mulloy: FMC Adult Trauma Care Committee Dr. Bruce Rothwell: Peter Lougheed Centre (PLC) Trauma Committee Dr. Nancy Zuzic: Rockyview General Hospital (RGH) Trauma Committee Paediatric Trauma Committee Chairperson: Dr. Francois Belanger, ACH Trauma Committee Acknowledgment of former personnel: Ms. Michelle Mercado, Administrative Assistant, Regional Trauma Services Ms. Nancy Guebert, Director, Inpatient Surgical Services & Trauma Services Ms. Kathy Cassidy, Interim Director, Inpatient Surgical Services & Trauma Services Welcome to New Personnel: Ms. Monica Rodriguez-Galvez, Regional Trauma Services Administrative Assistant Ms. Toni MacDonald, Director, Child Health Programs, Child and Women s Health Portfolio Ms. Marg Semel, Director, Inpatient Surgical Services & Trauma Services Mr. Laurie Leckie, Regional Paediatric Trauma Coordinator Ms. Joanne Bouma, Regional Adult Clinical Nurse Specialist Special Acknowledgments: Dr. Robert Mulloy, Interim Regional Trauma Services Medical Director for leadership and service to the trauma program Dr. Bruce Rothwell, Interim Regional Trauma Services Medical Director for leadership and service to the trauma program Dr. Francois Belanger, Interim ACH Trauma Director for leadership and service to the trauma program Dr. Kent Ranson, Regional Trauma Research Coordinator for review and advice on the annual report Ms. Monica Rodriguez-Galvez, Regional Trauma Services Administrative Assistant and Ms. Michelle Mercado, Data Analyst for compilation of the 2005/2006 Annual Report. - i -

5 REGIONAL TRAUMA SERVICES Calgary Health Region Vision: Healthy Communities Mission: Leaders in Health a partner in Care Values: Caring, respectful relationships, quality and safety, accountability Regional Trauma Services Vision: Excellence in trauma service delivery based on adequate financial and human resources, research-based quality improvement and education within a community that values integration, comprehensive rehabilitation and prevention. Mission: To provide and support a comprehensive, integrated and optimal system for the prevention, treatment and rehabilitation of injury focusing on the individual, family and community. Values: Respect: non-judgmental acknowledgment of the unique contributions, dignity and worth of individuals, being able to disagree, value diversity. Caring: sensitivity to and support for the well being of all. Accountability: willing to give an account of/be responsible for ones autonomy (where autonomy = actions/decisions taken within ones area/scope of responsibility). Teamwork: a commitment to work together towards common goals through effective communication, collaboration and tolerance for differences. Growth: personal and organization commitment to lifelong learning; continuous improvement; mentoring and sharing. Quality/excellence: in care and practice/work; clear standards; continuous improvement. Roles: Provide care to those affected by trauma within Region 3, Southern Alberta, Southeast British Columbia, and Southwestern Saskatchewan. Develop/advance clinical services, education and research at Regional, Provincial and Federal levels. Act as a clinical/education resource for rural & other urban communities. Provide acute care services including emergency care, diagnostic imaging, operative & critical care, ongoing surgical management & rehabilitation. Link to, and support disaster planning services, prevention programs, pre-hospital care, rehabilitation & other trauma programs. Maintain the trauma registry database and report on patients with ISS > 12 (Foothills Medical Centre (FMC) and Alberta Children s Hospital (ACH). Review/report on injury discharge data and emergency transfers, and maintain the trauma registry database data and report on patients with ISS > 12 at Rockyview General Hospital (RGH) and Peter Lougheed Centre (PLC). Assume a leadership role & active partnership in provincial and federal trauma services planning. Facilitate quality monitoring & improvement activities including the review & development of clinical practice guidelines, research initiatives, and the acquisition of applicable educational resources. Support the Trauma Association of Canada (TAC) as the TAC Central Office. - ii -

6 INTRODUCTION Medical Director s Message The Calgary Health Region provides comprehensive medical care to one of the most dynamic and rapidly growing populations in Canada. This sobering challenge is also combined with exciting opportunities to develop the premier clinical, academic, and innovative Trauma Service in the Country. This year s annual report continues to reflect the scale and significance of these activities. The broad coalition of health providers required to provide comprehensive injury control and advance the knowledge of injury is immediately apparent within. The strength of the Calgary Health Region s Trauma Service delivery of care model is reflected in the continuing dedication to good clinical care measured by accepted benchmarks, complemented by an ever-increasing number of publications and research dollars earned. It is a special opportunity in ones career to have recently inherited such a recognized and committed trauma program, supported by the highest level of administration and rich in talented personnel who wish to provide ever better care. The Calgary Health Region Trauma System continues to lead the country in reporting and benchmarking. Calgary s recognized strengths include comprehensive and coordinated pre-hospital ground and air ambulance services, single coordinated regional Emergency Department and Critical Care Departments, specialized surgical services including the dedicated Trauma Service and leadership in Spine, Orthopaedic, Reconstructive, Neurosurgical, Rehabilitative, and Vascular Surgery services. It is not surprising that the Trauma Association of Canada reflects these strengths in the high accreditation standing as a trauma system. As demonstrated herein, the Calgary Health Region continues to be the only region in Canada which strives to display transparency to the Public by publishing comprehensive performance indicators in the public domain. In doing so, we publicly commit to providing a high clinical standard and challenge other trauma care systems to do the same. This is not meant to be competitive or adversarial, only to stimulate good clinical care across the country. Locally, a major on-going initiative targeting better care for all Albertans, but especially those living outside the major population centers of Edmonton and Calgary is the Provincial Trauma System Proposal, promulgated in coordination with the Alberta Centre for Injury Control & Research. Initial groundwork has been laid by the Lethbridge Regional centre, and other district centers are expected to expand and organize in the next few years. The challenge for the future is to preserve these successes and to continue to provide excellent care across the clinical continuum for all Albertans despite the continuing systemic stresses accompanying rapid growth. We also hope to increase the already good research and teaching productivity across the multiple-disciplines involved in the delivery of regional trauma care. The Calgary Health Region is of necessity, pursuing an ambitious plan of expansion across the Region, most notable for the construction of the South Hospital. Regional Trauma Services has been actively involved in these discussions focused towards creating the footprint and future staffing to allow this resource to assume an appropriate role in the Regional Trauma Plan. Andrew W Kirkpatrick CD MD MHSc FACS FRCSC Calgary Health Region - iii -

7 Regional Trauma Services EXECUTIVE SUMMARY Prepared By: Ms. Dianne Dyer, Manager Regional Trauma Services

8 EXECUTIVE SUMMARY The Regional Trauma Services Program is dedicated to supporting and evaluating the provision of optimal trauma care to individuals and families affected by traumatic injury across southern Alberta, southeastern British Columbia and southwestern Saskatchewan. Services provided by the program include the provision, ongoing development and advancement of clinical care, education and research pertaining to trauma patients and families across the continuum from prehospital care to discharge to the community. The team continues to collaborate with partners within and external to the trauma system to address identified needs and issues and ensure an efficient, effective integrated system of care. The annual report is a comprehensive summary of the Regional Trauma Services team activities, trauma statistics, performance measures, interrelated reports, and trauma research publication information. Data and trends for the past five years are presented. The report and data is focused on the April 1/ March 31 st /2006 year. Unique features this year are the inclusion of new projections for trauma numbers and a report from the Shock Trauma Rescue Society (STARS). 1. Regional Trauma Services Activities 1.1 Clinical The core component of the trauma service is the clinical role to provide, facilitate and evaluate clinical services. The goal is to improve and maintain the highest standard of trauma care through inter-disciplinary team collaboration, education and research. To support this goal clinical practice is enhanced through the development, implementation and evaluation of clinical practice guidelines, technology, and clinical collaborative projects. Note: Current protocols and practice guidelines are available to clinical providers on the Regional Trauma Services internal website and in the revised Trauma Orientation Manuals for both adults and children. An external web site is also accessible with information on programs, services, related links and copies of the annual reports. Some of the clinical activities this year included: addressing concerns regarding safe and competent spinal management; designing and implementing a protocol focused on the management of blunt vascular trauma to the neck; the development of a Family Support pamphlet; implementation of a Blunt Traumatic Aortic Arch protocol; preparing a proposal to improve and support the care of the paediatric trauma patient (age < 14); completing the Spinal Injury Pathway guidelines in partnership with the ICU; evaluating the Paediatric Hypothermia protocol; revising the Trauma Team Activation paging process; updating the Regional Trauma Transfer policy; and piloting a Brief Intervention protocol focused on patients involved in alcohol related trauma or with potential alcohol related risk behaviours. 1.2 Education Promoting educational opportunities for clinical providers, managers and support staff is essential and integral to an effective trauma program. Educational activities this year included the presentation of Trauma Rounds on a weekly and/or monthly basis. The adult monthly trauma rounds were presented on Telehealth at all acute care sites and rural sites (upon request). Members of the Regional Trauma Services team participated in and/or presented at the joint Trauma Association of Canada (TAC)/Pan-American Trauma Society Scientific meeting held in Banff Alberta, March 22-26/2006. The Calgary Health Region team was responsible for planning the event this year. Team members were fully funded to attend using external sources and minimal operations funding. Physicians and nursing students were provided practicum and clinical rotation opportunities. Members of the team worked closely with the coordinator of the PARTY program to provide feedback, instructor support and support for the program. The trauma program continues to support Advanced Trauma Life Support (ATLS) and other educational and teaching programs

9 1.3 Quality Improvement The measurement and evaluation of various components of the adult and paediatric trauma system is an important focus of the work of Trauma Services. Throughout the year trauma care providers made referrals to Trauma Services with specific concerns for follow-up. The ACH and FMC trauma and audit committees conducted quarterly and ad hoc reviews of Trauma Registry statistics, performance indicators and audit filters. The PLC and RGH site trauma committees conducted quarterly and ad hoc case reviews and started reviews of major trauma charts/reports using Trauma Registry data. Standards and benchmarks applied to other trauma organizations were reviewed. Morbidity & Mortality (M & M) rounds were facilitated and data was collected identifying issues, deaths, and complications. Performance indicators, audit filters and clinical practice guidelines were reviewed and updated as appropriate. 1.4 Research Trauma research and evidence based practice is an essential focus of Trauma Services and an effective trauma system. A multitude of research activities were undertaken including participation in inter-provincial projects with British Columbia and other partners across the country. Members of the Regional Trauma Services team continued to participate in the Regional Nursing Research Committee, various interdisciplinary research projects and attend research courses and workshops. $12,199, total funding was received to support trauma related research projects this year. A comprehensive list of research publications, projects, funding sources and related information are included in the appendices section of this annual report. 1.5 Administration Administrative support is essential to the co-ordination of the various trauma services activities. This year one unique activity was participation by some members as accreditors representing the Trauma Association of Canada (TAC). This role provided the opportunity to review, evaluate and learn from other trauma programs and systems across the country and provide leadership, direction and support to the various teams. Team members continued to promote the integrated Provincial Trauma Proposal. Other administrative activities included: acquisition of funding to support weekly and monthly Trauma Rounds, the Trauma Nurses Journal Club, and educational opportunities for staff; acquisition of funding from TAC to support the TAC central office coordinator role within Regional Trauma Services; acquisition of funding to provide ATLS secretarial support; submission of a Province Wide Services (PWS) annual report and the successful acquisition of increased funding for the trauma system; preparation of a proposal to improve and support the care of the paediatric trauma patient (age < 14); and on-going facilitation of communication across the system encouraging input and feedback on trauma patient care issues and protocols. 1.6 Human Resources Members of the Trauma Services team participated in the Search & Selections committee for the new Trauma Medical Director. The search process was on going at the time period of this report. Dr. Robert Mulloy assumed the interim Trauma Medical Director role commencing November 2004; followed by Dr. Bruce Rothwell commencing January A new model of Clinical Nurse Specialist coverage was implemented using a part-time shared role. The Regional Pediatric Trauma Coordinator role was increased from part-time to full-time. 1.7 Data Management As part of TAC guidelines, an accredited trauma centre must have a trauma registry. Both FMC and ACH have stand-alone trauma registries. PLC and RGH also have stand-alone registries as part of the Trauma System. To qualify for the trauma registry a patient must have an ISS > 12 and be admitted to the trauma centre or die in the emergency department of the trauma centre. ISS is an anatomical scoring tool that provides an overall score for - 2 -

10 patients with single system or multiple system injuries. The higher the ISS, the more severe the patient s injuries. To ensure all appropriate patients are included into the trauma registry, all injury admissions, discharges and emergency department resuscitations are reviewed at FMC and ACH. This fiscal year, 3870 FMC patient records and 798 ACH patient records were reviewed to determine eligibility for the trauma registry. This was an 11.2 % increase in data analyst workload at FMC (3479 records: 2004/2005) and 11.6% at ACH (715 records: 2004/2005). For the first time, starting in May 2005, charts were also reviewed for trauma registry eligibility at PLC (267 records) and RGH (314 records). Once registry eligibility was determined for all sites, data was abstracted from the patient record and entered into the trauma registry. This was a manual process although efforts are on going to develop interfaces electronically with the trauma registry from TDS 9000, Quality System (QS) and Regional Emergency Department Information System (REDIS). Data was retrieved and analyzed for internal quality improvement initiatives with Regional Trauma Services (FMC, ACH, PLC and RGH Trauma Committees) and with departments involved in the care of the trauma patient. One way the performance of the overall trauma system is measured is by collection, documentation and review of 42 performance indicators. Thirteen of these are related to patient flow and outcome. Twenty-nine of these are related to clinical benchmarks. All major trauma patients are evaluated to determine if they meet the inclusion or exclusion criteria for each of the individual performance indicators. Data management workload is directly impacted by the number of performance indicators, as well the number of data elements, collected on each major trauma patient. In 2005/2006, the indicators focused on trauma/general surgery (24.1%), orthopaedics (24.1%), Emergency (10.3%) and multiple department/services (24.1%). Other departments comprised the remaining 17.4%. 2.0 Trauma Statistics & Outcome Indicators (FMC & ACH) 2.1 Major Trauma Totals Major trauma patient numbers and other related data included patients with an Injury Severity Score (ISS > 12) and were admitted to hospital or died in the FMC, ACH, PLC and RGH emergency departments. Based on these inclusion criteria, at the Trauma Centres these totals represented 26.8% (24.9%: 2004/2005) of injury discharges at FMC and 10.9% (11.9%: 2004/2005) of injury discharges at ACH. In the fiscal year 2005/2006, the FMC total was 969 patients (895: 2004/2005). The ACH total was 87 patients (88: 2004/2005). FMC experienced an 8.0% increase in annual totals and ACH experienced a 1.1% decrease. Adding the PLC and RGH major trauma cases to the total, the number of major trauma patients for this year was 1109 patients (1020: 2004/2005). The total number of overall traumatic injury discharges for the Region in 2005/2006 was 7829 patients. This was a 2.2% increase from the previous year (7659: 2004/2005). The Quality Safety Health Information (QSHI) projection for major trauma numbers by the year 2016 for Foothills Medical Centre was 1438 patients based on population growth, aging growth and growth in the incidence rate of trauma events. 2.2 Gender/Age Adult male patients consistently out numbered females in 2005/2006 by 3:1. In 2004/2005 the ratio was 2.8:1. At ACH the male to female ratio was 2.3:1; a 62.4% increase in the ratio from 2004/2005. Data collected at the FMC continued to demonstrate the national trend for age; with the majority of the trauma population between the ages of 15-44, with the greatest representation in the year old age range. The age group 65 and over was 24.6% (19%: 2004/2005) coinciding with national trends of an aging population. At ACH, there was an increase in the number of patients injured >/= 10 years to 58.6% (52.3%: 2004/2005)

11 can range from days to months. The LOS at ACH decreased from 5 days in 2004/2005 to 2 days in 2005/2006. In 2005/2006, the highest percentage mortality was in the older adult trauma patients (65+) with the highest in that age group in the > 84 year population. Of the younger adult age groups (< 65), 10% died (8%: 2004/2005). At ACH, in 2005/2006 the 1-4 age group experienced the highest mortality at 18% with falls as the cause of death. In 2004/2005, the 5-9 age group experienced the highest mortality (19%) with MVC as the major cause of death. At FMC, At the FMC, falls claimed the highest percentage of lives (13.4%) followed by transportation (13.3%), then violence (12.1%) and lastly other at 12%. At the ACH, mortality was highest in the other category at 11%. Falls followed at 7.4%, transportation at 7.3% and no deaths occurred in the violence category. In 2004/2005, violence had claimed the highest number of lives at FMC and ACH. The overall mortality rate at FMC was 13.1%, an increase from 2004/2005 at 10.9%. The overall mortality rate at ACH was 8% for 2005/2006, a decrease from 11.4% in 2004/2005. The majority of all of the major trauma patients were discharged home. 2.7 ISS > 16 Major Trauma Population In 1992, the inclusion criterion for the Trauma Registry was an ISS > 16. In 1993, this was revised to an ISS > 12. At FMC, the number of major trauma patients with an ISS > 16 was 805. There has been a 24.2% increase in the number of patients with an ISS > 16 over the last 5 years (2001/2002: 648 patients). At ACH where there was a decrease in this population to 68 patients when compared to 2001/2002 (86 patients). This rise in major trauma cases at FMC has resulted in increased pressures on acute care and community resources, with demands for improvements in access to services, performance, technology and efficiency measures. 3.0 Trauma Statistics (PLC & RGH) The RGH and PLC Trauma Committees reviewed all of the major trauma admissions (ISS 12). All of the admissions were assessed. In some cases, specific site issues or challenges were identified and referred to the specific departments for follow-up. Patients may arrive at these sites by ground ambulance, walk-in or private vehicle. The patients were identified for review using the three processes outlined in the PLC/RGH trauma statistics section of this report. At PLC, in 2005/2006, 192 discharged cases were reviewed and 20 ISS > 12 cases were admitted and discharged from the site. At RGH, 263 discharged cases were reviewed and 33 ISS > 12 cases were admitted and discharged from the site. At PLC, in 2004/2005, 10 major trauma patients (ISS > 12) were admitted to the site; at RGH, 28 major trauma patients were admitted. 26 major trauma patients arrived at PLC and were transferred and admitted to FMC. 37 patients arrived at RGH and were transferred to FMC for admission. The major trauma patients at RGH tend to be older in age overall than the patients at PLC. 4.0 Regional Trauma Statistics Injury Statistics There was a 2.2% increase (170 patients) in overall injury discharges from 2004/2005 to 2005/2006. The number of overall major trauma patients, for all sites combined, increased by 88 patients or 8.6% (total = 1109 patients). This year there was no evidence of a consistent peak period during one month or grouping of months for adult trauma injury discharges across all sites. The ability to accurately plan for peaks in adult trauma patient numbers, and therefore staffing resources, was difficult. The patients < 18 years demonstrated a more consistent pattern of injury discharges with an increases in the summer months; with higher overall numbers of patients admitted at ACH

12 5.0 Performance Indicators As part of the Regional Trauma Services quality improvement process, several indicators were monitored on a regular basis as a measure of performance throughout the continuum of care. The following is a summary of these indicators at Foothills Medical Centre and the Alberta Children s Hospital for patients who met the inclusion criteria for the Alberta Trauma Registry (patients with an ISS > 12 and who were admitted to the hospital or died in the ED). 5.1 Foothills Medical Centre Each performance indicator number was applied to a total population of 969; at time of publication. The FMC Quality Improvement/Quality Assurance Committee and Trauma Services reviewed the data and charts, and addressed identified issues as appropriate Transports/Transfers There were minimal differences in the transport data within the Region this year. There was a change in the number of major trauma patients (ISS > 12) transferred from the PLC and RGH sites to FMC site (i.e. PLC: 26: 2005/2006, 33 in 2004/2005; RGH: 37 in 2005/2006, 28 in 2004/2005). In the Provincial Trauma Proposal (November 2005) five centres were identified as proposed District Trauma Centres: Lethbridge Regional Hospital, Medicine Hat Regional Hospital, Red Deer Regional Hospital, Queen Elizabeth II Hospital, Grande Prairie, and Northern Lights Regional Hospital, Fort McMurray. In the proposal, each identified District Centre strives to become a Trauma Association of Canada accredited trauma centre, which includes the establishment of a trauma team, a trauma registry and adequate educational and equipment resources. 95 patients were transferred to FMC from one of the proposed District Centres (94 patients: 2004/2005). The number of out of province transfers to FMC increased to 72 from 44 in 2004/2005. This was a 63.6% increase over last year. Of the 72 out of province transfers, 66 or 91.7% of the patients were transferred from British Columbia Pre-Hospital Phase Use of a mechanical airway as an intervention for patients with a Glasgow Coma Scale (GCS) score < 8 at the scene is the standard of care. In the pre-hospital phase 41.7% of patients with a GCS < 8 (a measure of neurological status) had a mechanical airway. This was a decrease from the last year (52.7%). Of the 70 patients that did not receive a mechanical airway, 9 had a laryngeal mask airway (LMA) Resuscitative Phase The Trauma Team Leader (TTL) response time should be within 20 minutes of arrival of the patient to the trauma centre. This year this criterion was met 95.9% of the time (96.9% in 2004/2005). Some revisions were made to the trauma team activation call-out process this year to include an alphanumeric page with a text message. There were instances where the trauma team was activated and the patient injury severity score was < 12. In 2004/2005 there were 353 documented trauma team activations in total, 209 patients were classified as major trauma (ISS 12). In this fiscal year, of the 154 cases in which the criteria were met but the team was not activated (115 cases: 2004/2005), 64 or 40.9% were single system head injured patients. In many of these cases, neurosurgery was called directly to assess and treat the patient. Use of a mechanical airway as an intervention for patients with a Glasgow Coma Scale (GCS) score < 8 in the Emergency Department is the standard of care. In the ED, compliance with this indicator increased from 75% in 2004/2005 to 76.7% in 2005/2006. The length of stay for major trauma patients in the ED increased in 2005/2006. The ED length of stay was < 4 hours 36.7% of the time for 2005/2006 and 42.4% of the time in - 6 -

13 2004/2005. The average length of stay was 6.8 hours; median 5.3 hours for the 2005/2006 year. This increased LOS is reflective of the many access challenges being addressed within the system Definitive Phase Of the Category #1 laparotomy patients (hemorrhagic shock), 42.9% (16 patients) went to the OR within one hour, compared with 69.6% (16) last year. The median time to the OR for this category of patient was 59 minutes compared to 50 minutes in 2005/2006. The Bone & Joint program has appointed a Head of Orthopaedic Trauma for the 2005/2006 year; meetings with the Trauma Program have started and work is underway to address opportunities for quality improvement. An Orthopaedic Clinical Nurse Specialist was also hired to support the program. Four new orthopaedic indicators were added in 2004/2005. These new indicators focused on pelvic fractures and acetabular fractures and there was 100% compliance with the times to provisional stabilization and definitive repair. The time for joint dislocation to reduction standard is one hour from time of arrival. Compliance increased from 29.4% (2004/2005) to 41.2% for ; ankle dislocations were removed from this indicator criterion for the 2005/2006 year. The time for femur fracture to operative management standard is 24 hours. Compliance increased from 86.8% (2004/2005) to 87.3% this year. The compliance with timing for long bone open fracture operative repair decreased from 90% (2003/2004) to 83.3% last year to 62.8% in 2005/2006. All cases of non-compliance were reviewed and all indicators were reviewed and approved by the Division of Orthopaedics for the 2006/2007 year. For 2006/2007, the joint relocation indicator wording will be revised to recognize and record timely attempts to relocate the joint within one hour. The focus is on rapid intervention and consultation as required. The time to craniotomy for a patient with a subdural or epidural standard is within 4 hours of arrival to the trauma centre. Compliance decreased from 88.9% (2004/2005) to 79.3%. The percentage of patients with a missed injury/delayed diagnosis increased from 0.6 % in 2004/2005 to 2.5% in 2005/2006. Of the missed injuries 45% were extremities, 13.6% were abdominal, 9.1% were thorax, 9.1% were head and 4.5% were spine. In 2004/2005, the indicator was changed to include a time frame of 48 hours from arrival to allow time for the tertiary survey. There were no missed c-spine injuries this year. There was 50% compliance with the indicators for management of ischemic limbs (n=2) for the 2005/2006 year. Compliance was 93.4% for time to operative management of spinal fractures and there was a slight decrease in compliance with operative management of facial fractures from 93.75% in 2004/2005 to 91.5% (i.e. patients received operative repair < 7 days post arrival). The immobile patient should receive documented thrombolytic therapy within 24 hours of admission to a trauma centre. There was improved compliance from 76.8% of the patients in 2002/2003; to 80.8% in 2003/2004; to 87.5% in 2004/2005 and now 93.4% in 2005/2006. The improvement may relate partially to the introduction of pneumatic stockings for all patients on the trauma unit (FMC - PCU 71) unless otherwise ordered Outcomes The percentage of patients who died within 24 hours, out of the total number of patients that died, decreased slightly from 58.8% in 2004/2005 to 44.1% this year. The mortality rate overall however; increased from 10.9% in 2004/2005 to 13.1% in 2005/2006. The number of patients that died with a probability of survival > 20% increased from 3.6% in 2004/2005 to 6.1% in 2005/2006. For , there was 1.69 more survivors per 100 than would have been expected from the major trauma outcome study (Trauma Score Injury Severity Score (TRISS) Methodology) compared to 1.93 in 2005/

14 5.2 Alberta Children s Hospital Each performance indicator was applied to a total population of 87 patients for the 2005/2006 year. All cases flagged by a performance indicator or an audit filter was reviewed by the ACH Trauma Audit Committee and Trauma Services to determine appropriateness of care. If the ACH Audit Committee identified cases where there were trends or issues, the committee provided the appropriate follow up on those cases Transport/Transfers ACH data indicated no change in the number of patients transported to ACH from a primary or secondary hospital by the Transport Team. 33 patients (80.5%) of the transfers did not utilize the service compared to 25 or 75.8% for 2004/2005. The majority of children transported to ACH arrived by ground ambulance. All cases not transported by the team were reviewed, to determine whether the patient would have benefited from the service. Cases of concern were followed up with the sending centre. The time spent at sending hospitals (outside of the Calgary Health Region) prior to patient transfer was < 2 hours in 29% of the cases (24% in 2004/2005). This indicator combined the secondary and the primary hospitals into the sending hospital. Injury time to trauma centre increased over 2004/2005; 82.1% of the patients (23/28) arrived at the trauma centre > 4 hours from time of known injury event compared to 73.9% of the patients (17/23 patients) in 2004/ Pre-hospital Phase Use of a mechanical airway as an intervention for patients with a GCS score < 8 is the current standard of care. In the pre-hospital phase 46.2% of the patients with a GCS < 8 (a measure of neurological status) had a mechanical airway; 44.4% in 2004/2005. In many cases there were unsuccessful attempts to secure the airway with a mechanical airway at the scene. Paediatric experts advise that it is best practice to move the injured paediatric patient from the scene quickly to acute care for intubation, if required, rather than attempt intubation at the scene. A literature review is underway to secure supporting evidence Resuscitative Phase There was a decrease in the ACH ED LOS (standard of < 4 hours) compared to last year. 62.1% of the patients met the standard last year compared to 61.1% in 2004/2005. Use of a mechanical airway as an intervention for patients with a GCS score < 8 is the standard of care. In the emergency department (ED), compliance with this indicator continued at 100% in 2005/2006. At ACH, activation of the trauma team is through emergency at the discretion of the ED physician. All major trauma cases were reviewed through the ACH audit process. The Trauma Team (Code 77) was activated 19 times in the 2005/ of the activations occurred between April and September of The Trauma Team activation process and criteria is currently under review at ACH Definitive Phase The time to operative management of femur fractures standard is 24 hours; 60% of the patients (3/5) met the standard, compared to 75.0% in 2004/2005. There were no patients that met the open bone fracture indicator this year. 100% (4 patients) met the standard for operative management of facial fractures. 100% of the patients requiring a craniotomy met the indicator of operative management within 4 hours (1 patient). There were no unplanned returns to the OR, any unplanned ICU admissions and readmissions. The percentage of patients with a missed injury/delayed diagnosis decreased from 3.6% in 2004/2005 to 1% in 2005/

15 6.0 Reports Outcomes Of the 7 patients that died, 3 patients died within 24 hours of admission. The percentage mortality overall decreased from 11.4% in 2004/2005 to 8% in 2005/2006. No patients died with a probability of survival > 20%. During , there were 2.82 more survivors per 100 than would have been expected from the major trauma outcome study (Trauma Score Injury Severity Score (TRISS) Methodology); 2.90 in 2004/2005. A number of reports were submitted this year from various trauma system partners for inclusion in the annual report. The reports include: City of Calgary Emergency Medical Services (EMS) Annual Report Shock Trauma Air Transport Society (STARS) Report The Office of the Chief Medical Examiner s Report The Regional Department of Emergency Medicine Report The P.A.R.T.Y. Program Report The Calgary Firefighters Burn Treatment Centre Report Two Tertiary Neuro-rehabilitation Program Reports Profile of Injuries in the Calgary Health Region These reports are an important addition to the annual report and demonstrate and support the complexity and magnitude of the integrated Calgary Health Region trauma system. 7.0 Future Directions These are just a few of the Regional Trauma Services projects planned for the next year: Review and update of the Regional Trauma Services team/program vision and balanced scorecard. A team retreat will be scheduled for spring 2007 Increased data analyst support with one additional full-time position and 1 part-time data entry position; with the goal of Quality Assurance reporting for all four acute care sites within a 3-6 month target) and the addition of prospective data collection Mortality & Morbidity rounds and database management Acquisition of external funding for staff education and Trauma Rounds Establishment of a full-time Regional Research Coordinator position to commence in Fall 2006; with expanded research project initiation, involvement and publication Establishment of a full-time Clinical Nurse Specialist and a Nurse Practitioner position; to support both the clinical, quality assurance and project work Continued Internal/External website management and development Regional and Public Communication Projects Province Wide Services Trauma Mapping Model further development and evaluation Telehealth Education and clinical linkage opportunity identification Simulator Project development and participation Electronic Health Record participation and support Review and revision of the paediatric spine injury protocols Provincial Trauma Proposal implementation Implementation of the Paediatric Trauma Project; with the goal to improve and monitor the trauma care provided to children at ACH (age </= 14 years) Continued work on the application of Trauma Registry to the data collection and case review process at the PLC and RGH sites Explore ways to measure patient and family satisfaction within the trauma system. Accreditation recommendation follow-up Participation in the planning process for the new South Campus (i.e. Hospital) Seek opportunities to benchmark trauma care with national and international groups - 9 -

16 Participation in the Trauma Association of Canada Executive, the Canadian Forces Liaison/Disaster Committee, and the Trauma Registry Information Specialists of Canada (TRISC) committee Participation in the planning for the TAC Scientific meeting & Conference to be held in Ottawa, May 2007 Provide advice/support to other trauma centres across Canada undergoing trauma accreditation review Participation on Trauma Association of Canada accreditation/verification teams Continue to support the Trauma Association of Canada as the TAC Central Office site Move the Trauma Services offices to a new location within the FMC site Move the ACH team members to their new location at the new ACH site Regional Trauma Services will continue to promote the integrated Provincial Trauma System and support system performance through data management and quality improvement projects and initiatives based on current trauma research, clinical evidence and measurement of performance. Note: On February 13 th /2007, prior to publication a letter was sent from Tapan Chowdhury, Executive Director, Health Authority Funding and Financial Accountability. The letter indicated that the entire submission for funding for the Provincial Trauma Proposal had been approved for annual funding through Province Wide Services beginning 2007/2008. For more information on the work of Trauma Services visit our web site at: Regional Trauma Services

17 Regional Trauma Services ACTIVITIES Prepared By: Ms. Dianne Dyer, Manager Regional Trauma Services

18 2.3 Mechanism of Injury/Type of Injury As in previous years, the mechanism of injury (MOI) or cause of injury was reported by four broad categories: transportation, falls, violence and other. These were in keeping with the focus of the Calgary Health Region s injury control initiatives. "Transportation" continues to be cited as the number one MOI in data collected at FMC and ACH, accounting for 42.7% and 47.1% of the registry cases respectively (FMC 50.2%, ACH 46.6% in 2004/2005). "Violent" causes of injury represent 10.2% (11.9%: 2004/2005) of FMC, and 1.1% (5.7%: 2004/2005) of ACH trauma registry totals. Falls claimed the highest percentage of lives in the adult population this past year. Type of injury categories are used to broadly describe the type of force that results in injury. In both the adult and paediatric population, the majority of injuries were the result of blunt forces. When comparing 2005/2006 and the 2004/2005 years at the FMC, there was a 12.8% increase in blunt trauma, no major increase in penetrating trauma, a decrease in burn related trauma and very little change in the Other category. At the ACH, blunt trauma decreased from 81 (2004/2005) to 76 (2005/2006), penetrating trauma decreased from 2 patients (2004/2005) to 1 patient (2005/2006). There was an increase in burn patients and a slight increase in the Other category. 2.4 Transports/Transfers 67.3% of patients were transported to the FMC Trauma Centre by ground ambulance, no change from 2004/ % of patients transported to the ACH were transported by ground ambulance, a decrease from 2004/2005 (59.1%). Air transports to FMC increased this past year by 8.1% from 2004/2005 (246 patients) to 266 patients, while air transports to ACH increased by 26.9% from 26 patients in 2004/2005 to 33 patients. 2.5 Physician Services/Surgical Procedures The majority of trauma patients at the FMC site were admitted under the services of the general surgeon (423), followed by the neurosurgeon (209) followed by the Intensivist (181). At the ACH, the ICU service (42) was responsible for the majority of trauma admissions, followed by paediatrics (19); includes hospital-based paediatricians. In 2004/2005, 30.6% of major trauma admissions were admitted to the FMC ICU. In 2005/2006, 31.3% of FMC trauma patients were admitted to ICU for the fiscal year. At ACH, 50% of major trauma admissions were admitted to the ICU in 2004/2005. In 2005/ % of the trauma patients (44) were admitted to the ICU. Access to ICU beds at both sites continues to present many challenges. Trauma patients may undergo a variety of specialized surgical procedures. There was an increase in the overall number of surgical procedures performed at FMC to 1343 in 2005/2006 (1284: 2004/2005). At ACH there was a slight decrease from 142 in 2004/2005 to 136 in 2005/2006. The number of orthopaedic procedures performed at FMC this year continued to increase from 444 in 2004/2005 to 526 in 2005/2006. Orthopaedic surgeons continued to perform the highest number of surgical procedures at FMC however; Plastic surgeons performed the highest number of procedures at ACH in 2005/2006. The procedures at FMC were performed during 647 operating room visits (659 visits in 2004/2005), requiring 1624 operating room hours (1623: 2004/2005). At ACH, surgical procedures were performed on major trauma patients during 59 operating room visits (48: 2004/2005) totalling 112 operating room hours (101: 2004/2005). 2.6 Outcomes Outcomes were identified through Trauma Registry using length of stay, age, major mechanism of injury (MOI), ISS scores, mortality rates and discharge location. The median overall hospital (Length of Stay - LOS) has demonstrated minimal change over the past 5 years at FMC. There was a one day decrease from last year at FMC (9 days: 2004/2005). This included the acute phase of the hospital stay at FMC, not the rehabilitation phase, which - 4 -

19 REGIONAL TRAUMA SERVICES ACTIVITIES Regional Trauma Service continues to provide support for trauma care in the following areas: 1. Clinical A primary role of the trauma service is to support, facilitate and evaluate the clinical services provided for trauma patients. The goal is to improve and maintain the highest standard of trauma care through interdisciplinary team collaboration, education and research. To support this goal, clinical practice is enhanced through the development, implementation and evaluation of clinical practice guidelines, technology, quality assurance activities, and collaborative projects with other services and departments. Note: Current protocols and practice guidelines are available to clinical providers on the Trauma Services internal website and in the Adult and Paediatric Trauma Orientation manuals. Clinical activities this year included: Facilitation of on-going trauma committee meetings at all sites with the intent to support the work of the committees, facilitate communication across the system and encourage input and feedback on trauma patient care issues and protocols. Facilitation of meetings to address concerns regarding safe and competent spinal management in the Diagnostic Imaging departments and emergency departments at all sites. The goal was to develop regional policies, protocols and guidelines and is in the final stages of policy and procedure development. Collaboration with physicians across the Region to design and implement a protocol focused on the management of blunt vascular trauma to the neck. Trauma services, neurosurgery, neurology, emergency and diagnostic imaging supported the project. A final protocol was developed and posted on the web site. Working in partnership with Social Work in the development of a Family Support pamphlet designed to assist trauma patients and families when transport from a rural centre to an urban centre was required. The pamphlet is in the final stages of development and contains directions, hospital information and ways for patients and families to best access resources within the Region. Collaboration with Surgical Services, Vascular Services, Cardiovascular Services and Diagnostic Imaging to support the implementation of a Blunt Traumatic Aortic Arch protocol for trauma patients. The equipment to support the process has been purchased and the Diagnostic Imaging Technologists have been cross-trained to ensure competency with the new equipment and the protocol. The protocol supports arch injury medical interventions at the FMC site and is posted on the web site. Assuming a role on the Acquired Brain Injury Advisory Committee and related committee work. Collaboration with multiple partners at the ACH and FMC site to prepare a proposal to improve and support the care of the paediatric trauma patient (age < 14). The proposal is expected to go forward to Administration for funding. Working to revise the Trauma Resident orientation manual. The goal was to distribute the manual to the residents prior to arrival for a rotation so that they have information regarding their role and expectations of the rotation. Monthly resident orientation was presented. Work is ongoing on this project. Completion of the Spinal Injury Pathway guidelines in partnership with the ICU staff, physicians, allied health partners and leadership. The project moved past the pilot phase and was implemented in the ICU. The next steps will include possible implementation on Unit 112 at FMC (the neurosurgical inpatient unit). Collaboration with the ACH, FMC and STARS partners to evaluate the Paediatric Hypothermia protocol based on clinical reviews. Work is on going to revise the protocol. Working to revise the Trauma Team Activation process to include a single alphanumeric page for all responders with a text message containing pertinent patient information. Ongoing work continues to evaluate the process. Working to continue to evaluate the Trauma Team Activations for major trauma patients as part of ongoing quality assurance reviews. If a case met the criteria for activation and the team was not called the case was flagged in Trauma Registry and reviewed. Patterns were identified and recommendations were proposed for action at the quality assurance meetings

20 Facilitation of the review of patient issues through M+M (Morbidity and Mortality) rounds as required and in conjunction with Friday noon teaching rounds. Working with Neurosurgery and other stakeholders to finalize the Guidelines for Neurosurgical Consults. The guidelines were designed to provide information and support to Emergency physicians and others related to assessment, monitoring and appropriate interventions/referrals/consults for patients with head injuries. The guidelines were posted on the web site and are being monitored and evaluated through the quality assurance reviews at the various trauma committee meetings. Working to complete a literature review and to develop a guideline for patients flying via Medivac or commercial airline following chest tube removal. Many patients are from out of town, out of province or out of country. Once they are stabilized and able to receive the required healthcare in the area of residence, they are transferred closer, or discharged, to home. This project is ongoing. Working with regional partners, stakeholders and administration to update the Regional Trauma Transfer policy. The revision was approved at the Regional Trauma Advisory meeting and at the Surgical Executive. The process is ongoing and the policy will be posted on the Regional web site once finalized. Collaborating with Social Work on Unit 71 (Trauma Unit) to implement a project focused on screening patients involved in alcohol related trauma or potential alcohol related risk behaviours. This was a new initiative with the hope that clinical providers could make a difference and potentially prevent alcohol related trauma in the future. The intervention was called Alcohol Screening and Brief Intervention, from the National Institute on Alcohol Abuse and Alcoholism, USA. The interview tool was designed to help patients relate alcohol use to the trauma event they have experienced in the hope that this insight might prevent future alcohol related traumatic events. Other benefits might include provision of support for those seeking to address their abuse of alcohol. The Clinical Nurse Specialists carried out the interviews during the pilot. If a patient was discovered to have alcohol related issues using the rating scale then further follow up and intervention took place by the Unit 71 Social Worker. This project faced some challenges and is ongoing. Working in partnership with Diagnostic Imaging to refine the day-to day processes for timely spinal clearance and reporting. This is an on-going project. A Regional spinal clearance guideline was finalized and was posted on the web site. 2. Education Educational activities included: Trauma Rounds on a weekly basis at FMC and on a monthly basis at both FMC and ACH. Rounds were well attended and included internal and external speakers on a variety of pertinent topics. The adult monthly trauma rounds were presented via Telehealth to all acute care sites and rural sites (upon request). Planning and coordination of the joint Trauma Association of Canada (TAC)/Pan-American Trauma Society Scientific meeting held in Banff, Alberta, March 22-26/2006. Some team members presented research projects and papers at the sessions. Team members were fully funded to attend using external sources and minimal operations funding. Calgary planned the event this year. Leadership and clinical guidance for clinical clerks, residents and Fellows during their trauma surgery rotations. The students were from Calgary, other provinces and other countries. Precepting a University of Calgary Master of Nursing student. The Clinical Nurse Specialists shared the role of preceptor. Working closely with the coordinator of the PARTY program to provide instructor support and advisory support for the program. ATLS Student Provider Courses: 2005: April 28-30, May 12-14, June 2-4, September 8-10, November : January 26-28, March 2-4 Instructor Courses: 2006: January

21 Dr. Richard Simons, in BC, is the Region Chief, ATLS. Dr. Mary van Wijngaarden-Stephens is the Provincial Chair for Alberta. Trauma Surgeon Course leaders include: Dr. John Kortbeek, Dr. Bruce Rothwell, Dr. Jim Nixon, Dr. Jeff Way, Dr. Ian Anderson and Dr. Andrew Kirkpatrick. There are 53 instructors in good standing: Anaesthesia (3), Emergency Department (13), General Surgery (23), Critical Care (5), Orthopaedic Surgery (6), Neurosurgery (1), Family Medicine (2). ATLS Coordinators in Calgary: Nancy Biegler RN MN (Patient Care Manager, Unit 71, Trauma Unit, started in 2004), Sandra Dowkes (Secretary, Calgary Health Region, started in 1998). Monica Rodriguez-Galvez provided administrative support for the program through the Regional Trauma Services office. The program moved under the leadership of the Department of Surgery, Calgary Health Region, in January Information provided by: Sandra Dowkes. Trauma Education Rounds SPONSOR ACKNOWLEDGEMENTS: SonoSite sponsored monthly FMC Grand Trauma Rounds. Wyeth helped to sponsor/fund an external speaker at the February 2006 rounds. Trauma Grand Rounds, FMC Auditorium, (Adult Program) April 1 May 27 Sept. 23 Oct. 28 Nov. 25 Jan 24 Feb 24 Mar Dr. Robert Mulloy, Ms. Dianne Dyer - TAC Review: Let s Talk about it Dr. Rohan Lall - Phosphodiesterase Inhibition Attenuates Stored Blood Induced Neutrophil Activation: A Novel Adjunct to Blood Transfusion Dr. Ian Anderson - Afghanistan: Threats and Responses Dr. Radjiv Midha - Management of Peripheral Nerve Injuries Dr. Morad Hameed - The Contributions of Randomized Trials to Shock Resuscitation in Trauma 2006 Dr. Chad Ball - South Africa: Contributions to Evolving Trauma Care Dr. Douglas R. Hamilton - Observations from the Lead Physician of the Astrodome During the Hurricane Katrina Disaster Cancelled NOTE: The Paediatric Monthly Rounds are listed in the Paediatric Trauma Report in this document

22 SPONSOR ACKNOWLEDGEMENTS: Thank you to Novo Nordisk, SonoSite, Wyeth and KCI for sponsoring FMC weekly rounds. FMC Trauma Friday Noon Conference Rounds, Date Presenter Topic April 6 Cancelled TAC Conference 13 Dr. Neel Datta Peripheral Vascular Injuries 20 Dr. Artan Reso &Colleen Ischemic Hepatitis in Trauma & Pregnancy O Sullivan 27 Dr. Shawn Darling Myocardial Contusions May 4 Dr. Rob Mulloy (facilitator) M & M Rounds 11 Dr. Owen Reid Resident Presentation 18 Dr. Samer Elkassem Bladder Injuries 25 Dr. Peter Kwan Abdominal Compartment Syndrome June 1 Dr. C. Schiemen Aortic Injury 8 Cancelled 15 M & M Rounds 22 M & M Rounds 29 Dr. Adriana Condello Diaphragmatic Injuries July 1 Cancelled CANADA DAY 8 Cancelled 15 Dr. Karrie Davidge NSAID: Orthopaedic Patients 29 Dr. Nadra Ginting Psychiatric Sequelae of Traumatic Brain Injury August 5 Cancelled 12 Resident Presentation Urethral Injuries 19 Cancelled 26 Cancelled September 2 Cancelled 9 Cancelled 16 Dr. Mike Monument Analgesic Management of Rib Fractures 23 Dr. Turkey Alharbi Case Review 30 Dr. Colleen Haney Anticoagulation in the Trauma Patient October 7 Dr. Kathryn Lanuke Cardiac Trauma 14 Matheieu Rousseau Management of Blunt Splenic Injury (Clinical Clerk) 21 Dr. Sultann Quireshi Role of FAST in Trauma 28 Cancelled November 4 Dr. Margriet Greidanus Issues in Paediatric Trauma 11 Cancelled 18 Dan Hill Clinical Clerk Zone 1 Penetrating Neck Injuries 25 Cancelled December 2 Cancelled 10 Dr. Marilyn Neufeld Mgmt of Agitation in Traumatic Brain Injury 16 Dr. Glen Vajcner Indications for Embolization in Abdominal and Pelvic Injuries 23/30 Cancelled

23 2006 Date Presenter Topic January 6 Dr. Andy Kirkpatrick Mortality and Morbidity Trauma Case Reviews 13 Dr. John Grant Skiing and Snowboarding Injuries in Trauma 20 Stacey Litvinchuk/Joanne Bouma Annual Report Mini Presentation 27 Dr. Ian Anderson Trauma Journal Club February 3 Dr. Terry Leung Blunt Mediastinal Trauma 10 Cancelled 17 Dianne Dyer Regional Trauma Services 2004/2005 Annual Report Presentation 24 Dr. Klassen Frostbite March 3 Dr. Oyedokun Tx of Lung Contusions in Trauma 10 Dr. Rohan Lall Pelvic Embolization in Trauma 17 Dr. Jeff Way M and M rounds 24 Cancelled TAC Conference 31 Dr. Rodriguez Electrical Injury in Trauma Teaching Opportunities University of Calgary weekly Trauma Resident Rounds Calgary Continuous Trauma Services University of Calgary weekly Trauma Conference Noon Rounds Calgary Continuous Trauma Services University of Calgary Undergraduate Trauma Seminars Calgary Continuous Trauma Services University of Calgary Critical Care City-wide Rounds, Calgary Continuous CPC FMC University of Calgary Academic Half-days Calgary Continuous Critical Care Resident Presentations Calgary Continuous TAC Annual Conference & Scientific Meeting Banff, Alberta March 22-25/ Quality Improvement The measurement and evaluation of various components of the adult and paediatric trauma system is an important focus of the work of Regional Trauma Services. Quality improvement activities throughout the year included: Daily case reviews on the nursing units and timely reporting and follow-up. The quarterly and ad hoc review of FMC and ACH Trauma Registry statistics and the revision of performance indicators and audit filters at trauma and audit committees. This applied to the major trauma population only. The review of the PLC/RGH trauma case quality assurance process. The discharge summary lists provided by QSHI (Quality Safety & Health Information) and the admission lists were reviewed for trauma cases at PLC and RGH for several months. A comparison was made identifying the number of missed cases between the two lists and no significant difference was identified. The review of admission lists was found to be very resource intense and discontinued in favour of use of the discharge lists. Cases were also identified through referrals, chart reviews and follow-up forms. A specific trauma registry data set was selected for PLC and RGH (or non-tertiary trauma centers) and entry into the registry

24 Quarterly and ad hoc quality assurance case reviews were done at the PLC and RGH site trauma committee meetings. The review of standards and benchmarks applied to other trauma programs in Canada and internationally. The facilitation of Morbidity & Mortality (M&M) rounds and completion of cards identifying complications, issues, and deaths for entry into the M & M database Reviewing, critiquing and creating reports, documents and policies from a trauma service perspective. On-going review of all deaths and all laparotomy cases through the chart audit processes. The participation by some team members as accreditors for the Trauma Association of Canada. The posting of new or revised protocols and guidelines on the internal web site for application to practice. The posting of the Trauma Services Annual Report on the internal and external web site and the Trauma Association of Canada web site as information for other programs. Working with Capital Health Region to finalize a provincial Data Dictionary for Trauma Registry and with national partners to finalize a national Data Dictionary. Two members of the Trauma Services team presented a talk on a panel on Quality in Trauma Care: A Life and Death Issue at the joint Trauma Association of Canada (TAC)/Pan- American Trauma Society Scientific meeting held in Banff Alberta, March 22-26/ Research Trauma research and evidence based practice is an essential focus of Regional Trauma Services. Research activities this year included: The Trauma Research fund at the University of Calgary was available for seed money to support the initiation of research by students and trauma care providers. Eligibility for funding was determined by the Adult Trauma Care Committee at FMC. A Trauma Nurses Journal Club continued to meet however; interest diminished throughout the year. There are plans to continue with the Journal Club in 2007 and seek ways to stimulate interest in the next year. Members of the Regional Trauma Services team continued to participate in the Regional Nursing Research Committee, various interdisciplinary research projects and attend research courses and workshops. Meetings have occurred to support several joint projects with the Vancouver research group in the next year. Funding for the projects has been secured. $12,199, total funding was received to support trauma related research projects. A comprehensive list of research publications, projects, funding sources and related information are included in the appendices section of this annual report. 5. Administration Administrative support is essential to the co-ordination and achievement of the various trauma services activities. This year the administrative support activities included: The continued promotion of the integrated Provincial Trauma Proposal. The goal is an integrated provincial system for trauma in Alberta, which aims to get the injured trauma patient to the right location, the right provider and the right services in a timely manner. Regional Trauma Services worked closely with Capital Health Region Trauma Services and the Alberta Centre for Injury Control and Research (ACICR) to present the proposal to

25 Regional leaders and administrators at the proposed District Centres. These centres included Lethbridge Regional Hospital, Red Deer Regional Hospital, Medicine Hat Regional Hospital, Queen Elizabeth II Hospital in Grand Prairie and the Northern Lights Regional Hospital in Fort McMurray. The proposal was revised in November 2005 to include a detailed budget, updated references and action plans. Maintaining ongoing links with the Trauma Association of Canada (TAC). Ms. Christi Findlay, Data Analyst, sat on the National Executive for the Trauma Registry Information Specialists of Canada (TRISC). Ms. Dianne Dyer sat on the TAC Executive representing the TAC Central Office and as Vice Chairperson for the Canadian Forces Medical Liaison/Disaster Committee. Dr. John Kortbeek and Dr. Andrew Kirkpatrick (TAC Executive Secretary) sat on the TAC Executive. Ms. Monica Rodriguez-Galvez, Trauma Services Administrative Assistant, assumed the role of the office coordinator for the TAC Central Office, located as part of the Calgary Regional Trauma Services Office. Acquisition of funding to support weekly and monthly Trauma Rounds, the Trauma Nurses Journal Club, educational opportunities for staff and staff resources. External and operational funding was acquired to send team members to the joint Trauma Association of Canada (TAC)/Pan-American Trauma Society Scientific meeting held in Banff Alberta, March 22-26/2006. The Regional Paediatric Trauma Coordinator position was upgraded from 0.5 FTE to 1.0 FTE; the CNS role funding was augmented by 0.2 FTE to develop two 0.6 FTE part-time positions. Acquisition of funding from the Trauma Association of Canada (TAC) to support the TAC central office coordinator role within Regional Trauma Services. Acquisition of funding from Advanced Trauma Life Support (ATLS ) to support the ATLS secretarial support role within Regional Trauma Services. Submission of annual reports to Province Wide Services (PWS). Participation in the FMC and Regional Disaster planning meetings to ensure input from Trauma Services and access to updates on new developments. Monitoring and management of the Trauma Research Fund and smaller research funds under the University of Calgary Financial Services Department. To date this process has worked very well for the various researchers and the program. Continued meetings with the Regional PWS representative to ensure input into PWS funding allocations. Submission of proposals, in partnership with various managers and senior administrators, for approval by PWS for increased data analyst support, increased clinical nurse specialist support, increased support for Unit 71, the Trauma Unit (e.g. increased social work, physiotherapy and occupational therapy coverage, educational funding, equipment funding) and increased diagnostic imaging support for ACH. Funding was approved in May Participation in the planning for the Simulator Education Centre. Trauma Services will be a partner in this Centre in the future. Facilitated on-going trauma committee meetings at all sites with the intent to support the various Chairs of the committees, facilitate communication across the system and encourage input and feedback on trauma patient care issues and protocols. Collaboration with multiple partners at the ACH and FMC site to prepare a proposal to improve and support the care of the paediatric trauma patient (age < 14). The proposal is expected to go forward to Administration for funding. Acquired PWS funding for the Trauma Registry upgrade to a Calgary Central Site Model, which would include FMC, ACH. PLC and RGH. Data started to be collected for RGH and PLC in May This process included selected performance indicators and audit filters. A team retreat was held in November 2005 to provide an opportunity for team building, visioning and planning for the future. Another retreat will be scheduled in Spring Began the discussions and planning for a move of Trauma Services from the FMC ICU Administration location to a new location at FMC. A new site had not been located at the end of this reporting period

26 Committee Representation: Calgary Health Region: ACH, PLC and RGH Trauma Committees FMC Adult Trauma Care Committee (ATCC) FMC Trauma Resuscitation Committee The University of Calgary Surgical Undergraduate Education Committee (SUGEC) The University of FMC Trauma Quality Improvement Committee (TQI) ACH Audit Committee Adult Critical Care Nursing (ACCN) Advisory Committee SW Portfolio Meetings Surgical Executive Committee FMC Site Manager meetings City-wide Surgical Managers meetings Site Surgical Process Operations Committee (SSPOC) Regional Disaster Planning Committee FMC Disaster and Emergency Response Planning Committee Calgary Injury Prevention Coalition Intensive Care Unit (ICU) Executive Committee ICU Quality Council Committee ICU Research Committee Aboriginal Health Injury Prevention Committee Regional Nursing Research Committee Spinal Cord Injury Pathway committee Provincial: Alberta Ambulance Medical Review Committee American College of Surgeons, Alberta Chapter Alberta Ambulance Advisory and Appeal Board Alberta Association of Registered Nurses Provincial Trauma Proposal Committee National: The TAC Conference Planning Committee The Canadian Trauma Trials Collaborative (CTTC) The TAC Accreditation Committee The TAC Executive Committee The TAC Abstract Review Panel The TAC Canadian Forces Medical Liaison/Disaster Committee The Royal College of Physicians & Surgeons of Canada Test Committee for General Surgery The Trauma Registry Information Specialists of Canada (TRISC) Committee Canadian Nurses' Association International: American College of Surgeons, Alberta Chapter American College of Surgeons Committee on Trauma & ATLS Subcommittee Editorial Review Panel, Journal of Trauma & Injury Calgary, Critical Care Fellowship Steering Committee

27 6. Human Resource Activities Mr. Laurie Leckie was hired as the Regional Paediatric Trauma Coordinator commencing on May 16 th /2005. The position funding was increased from part-time 0.5 FTE to full-time 1.0 FTE. The Clinical Nurse Specialist (CNS) position was augmented by 0.2FTE and then split into two 0.6 FTE positions in December 2005 to support staff requests for part-time with a new approach to the role. Ms. Stacey Litvinchuk CNS and Ms. Joanne Bouma CNS assumed the two part-time positions. Members of the Trauma Services team participated in the Search & Selections committee for the new Trauma Medical Director. Dr. Robert Mulloy continued in an interim role until November Dr. Bruce Rothwell assumed the interim role next. The process to hire permanently was on going at the end of this reporting year. Dr. Andrew Kirkpatrick accepted the position to commence in July Data Management As part of TAC guidelines, an accredited trauma centre requires a trauma registry. Both FMC and ACH have stand-alone trauma registries, in use since April The PLC and RGH, although not accredited trauma centres, implemented the registry in the fall of The software, Collector, was developed by an American company and is supported by Digital Innovation based out of Maryland, USA. This application is used by over 200 hospitals worldwide including hospitals in Canada, the U.S., Australia, New Zealand and Sweden. It is a complete data management tool and report writing package. To qualify for the trauma registry, a patient must have an Injury Severity Score (ISS) > 12 and be admitted to the trauma centre or die in the emergency department of the trauma centre. ISS is an anatomical scoring tool that provides an overall score for patients with single system or multiple system injuries. Each injury is assigned an Abbreviated Injury Scale (AIS) score and is allocated to one of six body regions (head, including cervical spine; face; chest, including thoracic spine; abdomen, including lumbar spine; extremities, including pelvis; and external). Only the highest AIS score in each body region is used when calculating the ISS. The three most severely injured body regions have their highest score squared and added together to produce the ISS score. The higher the ISS score; the more severe the patient s injuries. To ensure all appropriate patients are included into the trauma registry, all injury admissions, discharges and emergency department resuscitations are reviewed at FMC and ACH. This fiscal year, 3870 ( /05) FMC patient records and 798 (715 04/05) ACH patient records were reviewed to determine eligibility for the trauma registry. This is an increase of 11.2% at FMC and an increase of 11.6% at ACH from last year. Once registry eligibility was determined, data was abstracted from the patient record and manually entered into the trauma registry. Data collected includes patient demographics, mechanism of injury information, pre-hospital information, sending hospital information, trauma centre emergency department information, trauma centre inpatient information including operative information, injury diagnosis information, outcome information and specific audit filters and performance indicators. The Health Information Act (HIA), section 27(1) (g), outlines clearly the parameters whereby Trauma Services is authorized to collect this data: 27 (l) A custodian may use individually identifying health information in its custody or under its control for the following purposes: (g) for internal management purposes, including planning, resource allocation, policy development, quality improvement, monitoring, audit, evaluation, reporting, obtaining or processing payment for health services and human resource management

28 Effort is made to gather as much information as possible. In some cases, follow-up is necessary with pre-hospital providers and sending hospitals. Data is retrieved and analyzed for internal quality improvement initiatives with Regional Trauma Services (FMC, ACH, PLC and RGH Trauma Committees) and with departments involved in the care of the trauma patient. Following the appropriate approval process, the registry is also used as a source of data for research, resource utilization, education and injury prevention initiatives, and outcome studies. Collector supports unique projects by providing the ability to customize the trauma registry and to write queries and reports. One way the performance of the overall trauma system is measured is by collection, documentation and review of 42 performance indicators. Thirteen of these are related to patient flow and outcome. Twenty-nine of these are related to clinical benchmarks. All major trauma patients are evaluated to determine if they meet the inclusion or exclusion criteria for each of the individual performance indicators. Data management workload is directly impacted by the number of performance indicators, as well the number of data elements, collected on each major trauma patient. Up to 1300 data elements may be collected for each patient. The following clinical benchmark summary illustrates the number of indicators per department / service for major trauma patients arriving at the FMC. A similar pattern is seen for patients arriving at the ACH. For more information, please see the FMC and ACH Performance Indicator sections later in this document. Foothills Medical Centre Department or Service # of clinical indicators % total of overall clinical indicators Trauma / General Surgery % Orthopaedic Surgery % Emergency Department % Pre-hospital Care 1 3.4% Neurosurgery 1 3.4% Plastic Surgery 1 3.4% Spinal Service 1 3.4% Vascular Surgery 1 3.4% Multiple Departments / Services * % * This includes indicators that are patient specific as opposed to department or service specific. An example is unplanned return to the OR. This is related to the actual service involved in the surgery of a particular patient, not to a particular service or department. FMC and ACH data is submitted to the Alberta Trauma Registry (ATR) central site based at the University of Alberta Hospital (U of A) in Edmonton, Alberta. The central site also captures data from the U of A Hospital and the Royal Alexandra Hospital in Edmonton. Data is then submitted from the central site to the National Trauma Registry of Canada. Currently the information gathered at the PLC and RGH is not sent forward to the central site in Edmonton and the National Trauma Registry. In the future, inclusion of the PLC and RGH data in the submissions to the central site and the National Trauma Registry will provide a more comprehensive picture of major trauma in Calgary. Regional Trauma Services works closely with colleagues in Edmonton to develop and maintain a consistent data dictionary ensuring a comprehensive and comparative data set. Prepared by: Christi Findlay, Regional Trauma Services Data Analyst

29 8. Current Projects/Future Directions These are just a few of the Regional Trauma Services projects planned for the next year: Review and update of the Regional Trauma Services team/program vision and balanced scorecard. A team retreat will be scheduled for Spring 2007 Increased data analyst support with one additional full-time position and 1 part-time data entry position; with Quality Assurance reporting for all four acute care sites (within a 3-6 month target) and the addition of prospective data collection Mortality & Morbidity rounds and database management Acquisition of external funding for staff education and Trauma Rounds Establishment of a full-time Regional Research Coordinator position to commence in Fall 2006; with expanded research project initiation, involvement and publication Establishment of a full-time Clinical Nurse Specialist and a Nurse Practitioner position; to support both the clinical, quality assurance and project work Continued Internal/External website management and development Regional and Public Communication Projects Province Wide Services Trauma Mapping Model further development and evaluation Telehealth Education and clinical linkage opportunity identification Simulator Project development and participation Electronic Health Record participation and support Review and revision of the paediatric spine injury protocols Provincial Trauma Proposal implementation Implementation of the Pediatric Trauma Project; with the goal to improve and monitor the trauma care provided to children at ACH (age </= 14 years) Continued work on the application of Trauma Registry to the data collection and case review process at the PLC and RGH sites Explore ways to measure patient and family satisfaction within the trauma system Accreditation recommendation follow-up Participation in the planning process for the new South Campus (i.e. Hospital) Seek opportunities to benchmark trauma care with national and international groups Participation in the Trauma Association of Canada Executive, Canadian Forces Liaison/Disaster Committee, and the Trauma Registry Information Specialists of Canada (TRISC) committee Participation in the planning for the TAC Scientific meeting & Conference to be held in Ottawa, May Provide advice/support to other trauma centres across Canada undergoing trauma accreditation review. Participation on Trauma Association of Canada accreditation/verification teams. Continue to support the Trauma Association of Canada as the TAC Central Office site. Move the Trauma Services offices to a new location within the FMC site. Move the ACH team members to their new location at the new ACH site. Regional Trauma Services will continue to promote the integrated Provincial Trauma System proposal and support system performance through data management and quality improvement projects and initiatives based on current trauma research, clinical evidence and measurement of performance. Note: On February 13 th /2007, prior to publication a letter was sent from Tapan Chowdhury, Executive Director, Health Authority Funding and Financial Accountability. The letter indicated that the entire submission for funding for the Provincial Trauma Proposal had been approved for annual funding through Province Wide Services commencing 2007/

30 Regional Paediatric Trauma Report ALBERTA CHILDREN S HOSPITAL Prepared By: Dr. Francois Belanger Interim Paediatric Trauma Medical Director

31 PAEDIATRIC TRAUMA REPORT 2005/2006 Paediatric Trauma Report In the fiscal year , Dr. Robin Eccles continued in the position as Medical Director of Paediatric Trauma until August 31, Dr. Francois Belanger replaced Dr. Eccles as interim Paediatric Trauma Director. Mr. Laurie Leckie continued in his position as Regional Paediatric Trauma Coordinator. Our data analyst, Maria Vivas, continued to do a superb job in reviewing cases and maintaining the Alberta Trauma Registry data entry. Trauma Service Activities Clinical Coverage: We continued to offer high quality of care for the population 0-14yrs. Certain changes were instituted including funding for on site CT tech coverage for evenings and weekends and the inclusion of transfusion services in the Trauma Activation Criteria. Revised Trauma Audit process: A considerable amount of effort and time was spent in enhancing our trauma audit process. We instituted a revised audit intake sheet and a new method of case reviews by the trauma committee emphasizing emerging trends and critical quality/safety issues. Certain trends such as the need to review paediatric trauma activation criteria and team composition were raised as the result of these reviews. We also emphasized the need to act real time on issues emerging from recent cases. In addition we reviewed the trauma audit committee terms of references and, reviewed refined and expanded the trauma audit filters and performance indicators used at the Alberta Children s Hospital. As a consequence of this new process the audit committee was able to gain significant ground on the backlog of cases to be reviewed. 0-14/15-17yr ACH Trauma Review and Planning Project: This extensive process included a review of previous evaluations, consultation with major stakeholders and consolidation into a document that was presented to the ACH Trauma Committee, Child Health Advisory Council, FMC Trauma Committee, and Joint Adult/Paediatric Surgical Advisory Committee. Significant energy and resources were given to the development of a document that included a number of core items needed to provide high quality trauma care at the ACH, for the current population cared for (0-14yr) as well as for potentially caring for 15-17yrs old. Search for Paediatric Trauma Director: The roles and responsibilities of the paediatric trauma director were reviewed and a process for recruitment of a permanent director was developed. Calls and an advertisement for nomination was provided in November 2005 and several highly qualified candidates were interviewed in April/2006. Committee Representation: Alberta Children s Hospital Trauma Committee Trauma Committee Community Member Trauma Audit Committee Child Health Advisory Council Regional Injury Executive Committee Calgary Injury Prevention Coalition Alberta Children s Hospital Surgical Executive Committee Intensive Care Advisory Committee Mortality Review Committee

32 Education Mr. Laurie Leckie paediatric trauma coordinator provided a number of trauma related education sessions with Emergency and Intensive care nurses. A number of very exciting trauma rounds were organized and focused on clinical topics such as: Trauma Team Activation in Paediatrics, the most sensible approach, Pelvic Injuries in Paediatrics and Management of the Hypothermic Child. The rounds were very well attended. There was also a combined paediatric/adult/surgical trauma rounds given by Dr. Freud from Israel on May 2 nd /2006 on the topic of paediatric injuries in terrorist events Date Presenter Topic May 2005 Sept 2005 Oct 2005 Nov 2005 Dr. Osama Bawazir Dr. Vince Grant Dr. Elaine Joughin Dr. Katherine Ross Bladder and Urethral Trauma Trauma Team Activation Guidelines-the most sensible approach Pelvic Injuries in Paediatrics Management of the Hypothermic Child 2006 Jan 2006 Feb 2006 Mar 2006 Dr. Ulrich Amendy Dr Walter Hader Trauma Association of Canada Conference The role of Interventional Radiology in paediatric trauma Major Head Trauma Prepared by: Dr. Francois Belanger, Interim Paediatric Trauma Director

33 Major Trauma Statistics & Outcome Data FOOTHILLS MEDICAL CENTRE ALBERTA CHILDREN S HOSPITAL Prepared By: Ms. Christi Findlay, Data Analyst Regional Trauma Services Ms. Maria Vivas, Data Analyst Regional Trauma Services Reviewed By: Ms. Dianne Dyer, Manager Regional Trauma Services Dr. Kent Ranson Research Coordinator Trauma Services

34 MONTHLY TRAUMA TOTALS Monthly trauma totals include patients with an Injury Severity Score (ISS) > 12 and who are admitted to hospital or die in the emergency departments at the Foothills Medical Centre (FMC) and Alberta Children s Hospital (ACH). ISS is an anatomical scoring tool that provides an overall score for patients with single system or multiple injuries. The ISS captured in the Alberta Trauma Registry ranges between 12 and 75. The higher the ISS, the more serious the injury. Based on these inclusion criteria, these totals represent 26.8% of injury discharges at FMC and 10.9% of injury discharges at ACH. In the fiscal year 2005/2006, the FMC total was 969 patients. The ACH total was 87 patients. FMC experienced an 8.0% increase in annual trauma case totals, while ACH annual trauma case totals decreased by 1.1% in 2005/2006. August accounted for the largest monthly trauma case total at both FMC and ACH. Summer months accounted for high numbers of major trauma cases at both sites. Trauma numbers however, can be very unpredictable. FMC /2006 ACH /2006 # of patients # of patients Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar YEARLY TRAUMA TOTALS The FMC five-year trend demonstrated rising major trauma case numbers with an increase in 2003/2004 (11.4%), an increase in 2004/2005 (4.1%) and an increase again in 2005/2006 (8.0%). The ACH five-year trend, showed a decrease (6.1%) 2002/2003, an increase (4.3%) in 2003/2004, a decrease in 2004/2005 (9.3%), and another decrease (1.1%) in 2005/2006. FMC - 5 Year Trend ACH - 5 Year Trend # of patients # of patients /02 02/03 03/04 04/05 05/06 01/02 02/03 03/04 04/05 05/

35 Projected Major Trauma Cases Foothills Medical Centre Foothills Medical Centre Projected Trauma Cases 1,800 1,600 1,400 1,200 1, ,611 1,552 1,494 1,435 1,376 1,318 1,438 1,390 1,200 1,259 1,341 1,142 1,293 1,244 1,083 1,196 1,147 1,227 1,099 1,188 1,265 1,050 1,112 1,150 1, , Actual Cases Projected Cases 0 01/02 02/03 03/04 04/05 05/06 06/07 07/08 08/09 09/10 10/11 11/12 12/13 13/14 14/15 15/16 High Most Likely Low METHOD Prepared in collaboration with: Mr. Stafford Dean, Health Systems Analysis Unit, (QSHI) - The Health Systems Analysis Unit (HSAU) supports the monitoring and evaluation of the Region's health requirements and the services provided by the Health Authority. Dr. Andrew Kirkpatrick, Medical Director Regional Trauma Services Dr. Ken Ranson, Regional Trauma Research Coordinator December 2006 This trend was prepared based on a combined 3 1/2 % population and aging growth with an extra 1/2 % for a growth in the incidence rate of trauma events. The estimates assumed one standard deviation of uncertainty for the first-year estimate; increasing by standard deviations for each subsequent year. CALGARY HEALTH REGION: HISTORICAL AND PROJECTED POPULATION 1,600,000 1,400,000 1,200,000 1,000, , , , Historical Actual Growth: : 296,881 Projected Growth: : 333,

36 ADULT MAJOR TRAUMA PREDICTIONS: A DISCUSSION Trauma significantly impacts the health care system and the community. These new graphs demonstrate the projections for continued growth in the overall population and adult major trauma numbers over the next 10 years. The paediatric major trauma numbers were not included in these predictions as the numbers have levelled off or dropped in the last few years. Trauma is often predictable and preventable. Intentional and unintentional injuries are the leading cause of death of Albertans between the ages of 1 and 44 (Alberta Centre for Injury Control & Research, January 2006). The following list of Calgary Health Region issues impact all aspects of the health care system however; the growth of the injury population; more specifically major trauma population, escalates or compounds the impact on the system resources. The issues include, but are not limited to: 1. A growing population and an aging population in Calgary and surrounding communities. 2. Emergency Room overcrowding and increasing demand for services. 3. The growing shortage of ICU, inpatient, rehabilitation beds with pressures for access. 4. The need for timely access to limited home care and community resources. 5. Recruitment and retention of staff and physician challenges across the system. 6. The impact of trauma on the individuals, families and community. This may include impact on the quality of life, socio-economic status, potential years of life lost and the economic and social burden of injury on society. 7. The need for continued and innovative initiatives to prevent injury and injury risk. Background Information Falls and transportation continued to be the primary mechanisms of injury (cause of injury) in trauma; supported by the 2005/2006 data presented in this report. Falls Rates for fall-related injuries were the highest for both hospital and emergency department utilization in the Calgary Health Region in 2005/2006. The Profile of Injuries in the Calgary Health Region report indicated that 75% of all hospitalizations after age 65 and 60% of all emergency department visits were incidents related to falls. The admissions were over a third (36%) due to a hip fracture. In the major trauma population, the number of falls increased from 29.5% 2004/2005 (264) at FMC to 38.5% in 2005/2006 (373). In 2005/2006, falls caused the highest number of deaths in major trauma adults. Transportation Information from the Alberta Traffic Safety Plan: Saving Lives 0n Alberta s Roads, October 2006 indicates that the goal of the plan is commitment to reduced injury numbers and improved traffic safety. Website: Alberta Government: Infrastructure and Transportation: Some facts/quotes from the report (page 2-3): A traffic collision occurs in Alberta every five minutes and on average, at least one person will be killed and 65 will be injured every day in Alberta due to motor vehicle collisions. In Alberta, the overall cost of motor vehicle collisions to society is conservatively estimated to be at least $4 billion dollars per year. That s about $12 million every single day percent of the drivers involved in a fatal collision had consumed alcohol prior to the crash. 70 per cent of fatal crashes occur on rural roads. The discussion does not include the growing impact of violence and other causes of injury. It also does not include the startling results of the Regional Trauma Services Peer-Reviewed Research that revealed that over two-thirds of all injured drivers admitted to CHR hospitals with known illegal blood alcohol levels were never charged with any criminal offence; largely due to a lack of communication between medical and policing staff (Goeke, ME,Kirkpatrick, AK,et al, Clinical & Investigative Medicine, 2007, 30 (1), pp ). This annual report would not be complete without discussion of the impact of trauma on the Calgary Health Region and the community and discussion of opportunities for injury prevention (see The Profile of Injuries in the Calgary Health Region report in this document). Injury Prevention is our duty and responsibility as trauma experts, health care providers and citizens. The goal is to seek ways to prevent injury, minimize risks and therefore aim to reduce trauma numbers and therefore the impact on society

37 MALE/FEMALE As noted in previous trauma reports, males continued to out number females in the total adult and paediatric trauma population. Adult males consistently out numbered females 2:1. In 2004/2005 the ratio was 2.8:1. In 2005/2006, the ratio was 3:1. At ACH the male to female ratio for 2005/2006 is 2.3:1, a 62.4% increase in ratio from 1.4:1 in 2004/2005. FMC - 5 Year Trend ACH - 5 Year Trend # of patients # of patients /02 02/03 03/04 04/05 05/06 01/02 02/03 03/04 04/05 05/06 Male Female Male Female AGE DISTRIBUTION Data collected at the FMC continued to demonstrate the national trends. The majority of the trauma population was between the ages of 15-44, with the greatest representation in the age range. In this fiscal year, 51.1% of the trauma population was 45 or older, compared with 46.3% in 2004/2005. The age group 65 and over years of age was 24.6% of the overall population. At the ACH, the data indicated an increase in the percentage of trauma patients > 10 years of age, 58.6% (41 patients) this year compared to 52.3% (46 patients) in 2004/2005. FMC /2006 ACH / # of patients # of patients >84 < >14 *Unknown age: 3 patients

38 MECHANISM OF INJURY (MOI) As in previous years, MOI is reported by four broad categories: transportation, falls, violence and other. These are in keeping with the focus of the Calgary Health Region s injury control initiatives. "Transportation" continued to be cited as the number one MOI in data collected at FMC and ACH, accounting for 42.7% and 47.1% of the registry cases respectively FMC 50.2%, ACH 46.6% (2004/2005). "Falls" resulting in major injury accounted for 38.5% of patients at FMC. This was an increase from last year of 29.5% 2004/2005. ACH falls constituted 31% (27) of cases (28.4% 2004/2005). "Violent" causes of injury represented 10.2% (99) of FMC, and 1.1% (1) of ACH trauma registry totals (FMC 11.9%, ACH 5.7% 2004/2005). Limitations of the ISS scoring system in evaluating penetrating injuries that involve single system or single organ injuries may lead to under representation of violence. Other MOI contributed to 8.6% of the total at FMC (8.4% 2004/2005). At ACH 20.7% (18) patients were admitted for other MOI (19.3% 2004/2005). Other is defined as unspecified, or not within the three categories defined above. Please see Mechanism of Injury Other for further clarification. FMC /2006 # of patients Transportation Falls Violence Other ACH / # of patients Transportation Falls Violence Other The following four pages show a further breakdown of each category: Transportation Falls Violence Other

39 MECHANISM OF INJURY TRANSPORTATION Motor vehicle collisions (MVC) comprised 31.4% of all major traumas at FMC, a decrease from 37.7% last year. In the transportation category, MVCs represented 73.4% (75% 2004/2005) of all transportation related mechanisms of injury. At the ACH, MVCs accounted for 24.1% of all major paediatric trauma cases (compared to 20.5% 2004/2005). MVCs comprised 47.1% of the transportation category incidents which is up from 46.6% 2004/2005. FMC 2005/2006 ACH 2005/ # of patients # of patients MVC Ped Off Road Pedal Rail Aircraft/ Watercraft MVC Ped Off Road Pedal Water Air FMC - 5 Year Trend ACH - 5 Year Trend # of patients # of patients /02 02/03 03/04 04/05 05/06 01/02 02/03 03/04 04/05 05/06 According to the Profile of Injuries in the Calgary Health Region report, the transportation-related emergency department visit rates were high among young people; while the rates peaked between the ages of years. The rates were also relatively high between 5-14 years of age and between years of age. As with hospitalization, males were more likely than females to be seen at the emergency department for a transportation-related injury. Graduated driver licensing (GDL) was introduced in Alberta in May The GDL program introduced the probationary operator s license in between the learner s license and the full driver s license. The graduated program improves road safety by extending the learning stage for new drivers, helping them gain more experience and improve their skills before graduating to more demanding driving situations. Studies have demonstrated that some factors such as driver inexperience, distractibility or reckless attitudes may contribute to the number of collisions among this high-risk population of drivers. The program was designed to attempt to address these issues. Source: Alberta Child and Teen Major Trauma Report, 2002, p. 26). This initiative has been introduced in other provinces as well. Since the implementation of GDL, the number of casualty collisions by young new drivers has dropped a statistically significant amount. The rate of casualty collisions for drivers aged 16 and 17 years dropped from 28.8 per 1000 licensed drivers in 2002 (Alberta Transportation, 2003a) to 22.0 in 2004 (Alberta Infrastructure and Transportation, 2005). The rate dropped again in 2005 to 19.7 (Alberta Infrastructure

40 and Transportation, 2006). This is consistent with findings in other jurisdictions. Alberta has the opportunity to strengthen the GDL legislation that is currently in place and to further reduce the toll of traffic deaths and injuries to young new drivers. Night driving restrictions, passenger restrictions and a minimum amount of supervised driving are best practices in GDL that are not presently included in the Alberta legislation. For more info go to their web site at The Calgary Health Region, Injury Prevention and Control Services, works closely with the Alberta Occupant Restraint Program (AORP) to promote awareness of the importance of using car seats and booster seats for children from birth through to their 9th birthday. A series of self help resources entitled 'YES Tests' have been developed for rear facing, forward facing and booster seats and assist parents to properly install and use each type of seat. For additional information and to view and download these resources, please go to the Calgary Health Region website In addition, a special website was developed by Injury Prevention and Control Services to facilitate easier access to information specifically on booster seats ( Survey research with parents revealed that the need for booster seats for children between ages 4 and 9 was not well understood and that many parents continue to believe that an adult seatbelt will properly restrain and protect their young child. A variety of strategies are being used to raise awareness of the importance of booster seats including radio ad campaigns. Booster seat legislation is also under discussion in Alberta as part of the Alberta Traffic Safety Plan. Safe Kids Canada and Hudson s Bay Company worked together to create the Kids that Click program to support parents and caregivers when buying and using car and booster seats. The program launched nationally, on April 12, 2006 the Kids that Click program and provides education materials in participating Hudson Bay stores across Canada, to help parents select the right kind of child passenger restraint. More information can be found at the Safe Kids Canada website at MECHANISM OF INJURY - FALLS The number of falls in the adult trauma population continued to rise every year with the highest number in the multi-level category. Comparing age groups for adult males there was very little difference in the numbers; the number of falls for adult females increases with age. Falls increased from 29.5% 2004/2005 (264) in the overall major trauma population at FMC to 38.5% in 2005/2006 (373). The number of falls in children rose very high in 1999/2000 (40), dropped in numbers and then started to rise again in 2002/2003 (28). In 2004/2005, falls made up 31% of major paediatric trauma cases (25) and 28.4% in 2005/2006 (27). It is important to note that, due to the small sample numbers caution must be taken to generalize findings across the paediatric population. More females fall as they age, but in very young children, more males fall. Please refer to Gender/Age/Mechanism of Injury Pattern later in this section for more information. FMC /2006 ACH / # of patients # of patients 11 0 Multi-level Same Level Other/Unspecified Multi-level Same Level Other/Unspecified The incidence of falls in the older adult population may be under represented in this data due to the ISS > 12 scoring system for major trauma. Ground level falls are very common and may produce injuries and may be scored ISS < 12 (e.g. hip fractures). Fall prevention is a priority but support resources are limited

41 FMC - 5 Year Trend ACH - 5 Year Trend # of patients # of patients 18 01/02 02/03 03/04 04/05 05/06 01/02 02/03 03/04 04/05 05/06 Similarly, falls in the paediatric population may also be under represented. Ground level falls, and falls from playground and sporting equipment are very common and often produce injuries that are scored ISS < 12 (e.g. isolated extremity fractures). Compared to other mechanisms of injury within the Calgary Health Region, fall-related injury rates were the highest for both hospitalisations and emergency department utilisation. Please refer to the Profiles of Injuries in the Calgary Health Region document in this report for more detailed information. As will be stated later in the report, falls claimed the highest percentage of lives in the major trauma adult population this year. MECHANISM OF INJURY - VIOLENCE Incidents of violence in the FMC major trauma population remained fairly stable at 99 patients this year compared to 106 last year. There was an increase in unarmed assaults this year from 29 (12.1%) in 2004/2005 to 37 (37.4%) in 2005/2006. Assaults with an object decreased from 49 (46.2%) in 2004/2005 to 39 (39.4%) in 2005/2006. At the FMC, the number of patients with self inflicted violence remained constant at 15 (14.2%) patients in 2004/2005 and 16 (16.2%) this year. This figure does not include individuals who die at the scene of their injury event or intentional injury caused by poisoning. Violence characterized 1.1% of the ACH paediatric major trauma, down from 5.7% in 2004/2005. Unarmed assaults decreased from 60% (3) in 2004/2005 to 0% in 2005/2006. For male youth, there was an increase in violence in the greater than 14 year old age group. Female children showed an increase in the 1 to 4 year old age group and the year old age group. According to Injury Prevention and Control Services of the Calgary Health Region, December 2006, males, especially between the ages of 15 and 24, are far more likely than females to be hospitalized or visit an emergency department for a violence-related injury. If comparisons are made with females between 15 and 44 years of age, males are 3-9 times more likely to be hospitalized for a violence-related injury and two to three times more likely to be seen in the emergency department for an injury due to violence. In Calgary there are numerous activities aimed at prevention of violence. These may include: Alliance to End Violence, Calgary, AB, The YWCA Family Violence Prevention Centre & Sheriff King Home (YWCA Sheriff King) serves women, children, and men who have witnessed, experienced or have been abusive in an intimate relationship. For more information go to:

42 FMC 2005/2006 ACH 2005/2006 # of patients # of patients Unarmed assault Assault w ith object Self-inflicted Unknow n type of assault Unarmed assault Assault with object Self-inflicted Unspecified assault FMC - 5 Year Trend ACH - 5 Year Trend # of patients # of patients /02 02/03 03/04 04/05 05/06 01/02 02/03 03/04 04/05 05/06 Violence is under represented in the major trauma population. Many patients experience a violent assault, penetrating injury or other violent act and do not qualify for the Trauma Registry due to exclusion of many single-system organ or limb injuries. Agencies targeting prevention of violence in Calgary include: Coalition on Family Violence. the Calgary Immigrant Women's Association. Calgary Legal Guidance, Calgary Women's Emergency. For more information contact:

43 MECHANISM OF INJURY OTHER Mechanical MOI include injuries caused by machinery or a moving object, injuries sustained in or between objects, and injuries sustained when struck by an object or a person. Animal MOI includes animal attacks, and injuries sustained while riding, or in other contact with animals. FMC 2005/2006 ACH 2005/2006 # of patients # of patients Legend 1. Mechanical 2. Animal 3. Fire / explosion / electric 4. Environmental 5. Drowning 6. Other Legend 1. Mechanical 2. Animal 3. Fire/explosion/electrical 4. Environmental 5. Drowning 6. Ingestion 7. Unknown At both sites, there was a marked change in the number of patients injured by mechanical means from the previous year. At FMC, the patient number increased from 27 in 2004/2005 to 42 in 2005/2006. There was a noticeable decrease in the number of patients injured by fire/explosion/electrical events from 24 in 2004/2005 to 2 in 2005/2006. At ACH, the number of patients with injuries related to animals decreased from 7 to 1 and the number of drowning related incidents more than doubled in 2005/2006 to 5 from 2 last year. FMC - 5 Year Trend ACH - 5 Year Trend # of patients # of patients /02 02/03 03/04 04/05 05/06 01/02 02/03 03/04 04/05 05/06 Access to excellent injury prevention information (e.g. horse back riding, farm safety) for parents and children is available on the KIDSAFE Connection fact sheets that can be found at

44 TYPE OF INJURY Type of injury categories are used to broadly describe the type of force that results in injury. In both the adult and paediatric population, the majority of injuries were the result of blunt forces. At FMC, there was a 12.8% increase in blunt trauma from 2004/2005 (812) to 2005/2006 (916). There was no major change in penetrating trauma (45 patients: 2004/2005), a decrease in burn related trauma from 28 to 2 patients in 2005/2006 and very little change in other injury types. At the ACH, blunt trauma decreased from 81 (2004/2005) to 76 (2005/2006), penetrating trauma decreased from 2 (2004/2005) to 1 (2005/2006). Burns increased from 0 (2004/2005) to 4 (2005/2006). Other injury type represent a 20% increase - 5 (2004/2005) and 6 (2005/2006). FMC 2005/2006 ACH 2005/ # of patients # of patients Blunt Penetrating Burn Other Blunt Penetrating Burn Other Blunt Injury FMC - 5 Year Trend ACH - 5 Year Trend # of patients # of patients /02 02/03 03/04 04/05 05/06 01/02 02/03 03/04 04/05 05/06 Penetrating Injury FMC - 5 Year Trend ACH - 5 Year Trend # of patients # of patients /02 02/03 03/04 04/05 05/06 01/02 02/03 03/04 04/05 05/06 Penetrating trauma may not include patients sustaining a single system/single organ injury (i.e. ISS < 12) due to a stabbing incident and may include patients that fall or injure themselves on a sharp object

45 Burn Injury FMC - 5 Year Trend 28 ACH - 5 Year Trend 4 # of patients # of patients /02 02/03 03/04 04/05 05/06 01/02 02/03 03/04 04/05 05/06 For more information on adult burn cases (2005/2006) see the Calgary Firefighters Burn Treatment Centre report. Other Injury FMC - 5 Year Trend ACH - 5 Year Trend # of patients # of patients /02 02/03 03/04 04/05 05/06 01/02 02/03 03/04 04/05 05/06 DIRECT VS TRANSFER Direct means the patient was transported directly from the scene to a trauma centre; whereas, transfer means the patient was initially treated at another facility and then transferred to a trauma centre. In 2005/2006, 58.7% of patients were transported directly from the scene to FMC; 57.3% in 2004/ % (400) patients were transferred from another facility compared to 2004/2005 at 42.7% or 382 patients. At ACH, 51.7% of patients were transported directly from the scene (compared to 63.6% 2004/2005). 48.3% were transferred from another facility, compared to 36.4% 2005/2006. Direct vs. Transfer # of patients FMC - 5 Year Trend # of patients ACH - 5 Year Trend /02 02/03 03/04 04/05 05/06 Direct Transfer 00/02 02/03 03/04 04/05 05/06 Direct Transfer

46 INTERHOSPITAL TRANSFERS WITHIN CALGARY FMC 2005/2006 ACH 2005/2006 # of patients # of patients PLC RGH ACH PLC RGH FMC These patients were the major trauma patients that arrived at one site (e.g. PLC) by ground ambulance, walk-in or private vehicle and were transferred to FMC or ACH. GROUND VS AIR TRANSPORT Ground refers to ground (road) ambulance transport. Air includes fixed wing and rotary wing aircraft. In situations where both modes of transport are utilized to get patients to FMC or ACH, only the air transport portion was represented in this collection of statistics. 67.3% of patients were transported to the FMC Trauma Centre by ground ambulance, no change from 2004/2005 (67.3%). 45.9% of patients transported to the ACH were transported by ground ambulance, a decrease from 2004/2005 (59.1%). Air transport to FMC increased by 8.1% from 2004/2005 (240 patients) to 266 patients. Air transport to ACH increased by 26.9% from 2004/2005 (26 patients) to 33 patients in 2004/2005. Ground vs. Air FMC - 5 Year Trend ACH - 5 Year Trend # of patients # of patients /02 02/03 03/04 04/05 05/06 Ground Air 01/02 02/03 03/04 04/05 05/06 Ground Air Private vehicle/walk-in 2005/2006: 51 (5.3%) Private vehicle/walk-in 2005/2006: 14 (16.1%) Private vehicle/walk-in 2004/2005: 45 (5%) Private vehicle/walk-in 2004/2005: 10 (11.4%) Unknown mode of arrival: 0 Unknown mode of arrival: 0 NOTE: For more information on Ground and Air Transport see the City of Calgary Emergency Medical Services Trauma Report and the Shock Trauma Air Rescue (STARS) Society Report in this document

47 FMC Ground vs Rotary Wing /2006 Transport Direct From Scene # of patients Ground Rotary Wing Excludes patients arriving direct from scene via private vehicle/walk in ACH - Ground, Rotary, Fixed Wing /2006 Transport Direct from Scene # of patients Ground STARS Fixed Wing PHYSICIAN SERVICE ANALYSIS Excludes patients arriving via private vehicle/walk-in (13) The majority of trauma patients at the FMC site were admitted under the services of the general surgeon, followed by the intensivist. This complied with the performance indicator for quality trauma care and was closely monitored. General surgery admissions from previous years were 2004/ , 2003/ Other included hospitalists at the FMC site. This analysis does not include transfers of care, nor consulting services. At the ACH, the ICU service was responsible for the majority of trauma admissions, followed by paediatrics (includes hospital-based paediatricians) and paediatric surgery. In previous years, ICU service admissions were 2004/ , 2003/ FMC 2005/ # of patients GS ICU NS OS PS TS ENT OB/G Other Legend: GS - general surgery; ICU - intensive care unit; NS - neurosurgery; OS - orthopaedic surgery; PS - plastic surgery; TS - thoracic Surgery; ENT - ears, nose, throat; OB/G - obstetrics and gynecology; Other - hospitalists, psychiatrist, neurology

48 42 ACH 2005/2006 # of patients ICU Ped Ped Surg OS PS Other Legend: ICU - intensive care unit; Ped - paediatrician; Ped Surg - paediatric surgery; OS - orthopaedic surgery; PS - plastic surgery; Other - paediatric hospitalist SURGICAL PROCEDURES In 2005/2006, physicians performed 1343 surgical procedures on major trauma patients at the FMC (2004/ ). The procedures were done during 647 visits to the operating rooms, requiring 1624 operating room hours (2004/ hours). In 2005/2006 at the ACH, 136 surgical procedures (2004/ ) were performed on major trauma patients during 59 operating room visits, totalling 112 operating room hours (2004/ hours). 526 FMC 2005/2006 # of procedures OS PS GS NS Thor CV OB/G Urol ENT OPTH Other Legend: OS - orthopaedics; PS - plastic surgery; GS - general surgery; NS - neurosurgery; Thor - thoracic surgery; CV - cardiovascular surgery; OB/G - obstetrics & gynecology; Urol - urology; ENT - ears, nose and throat; OPTH - Ophthalmology; Other - anaesthesia, radiology, etc

49 57 ACH 2005/2006 # of procedures Ortho Plastics Ped Surg NS Urology Other Legend: Ortho - orthopaedics; Plastics - plastic surgery; Ped Surg - paediatric surgery; NS - neurosurgery; Urology - urology; Other - dentistry, otolaryngology, pulmonology, gastroenterology. Orthopaedics procedures continued to be the highest number of surgical procedures performed at FMC (39.2% compared to 34.6% or 444 in 2004/2005). In 2005/2006, 41.9% of procedures at ACH were performed by plastics and 27.2% by orthopaedics. ICU TRAUMA ADMISSIONS In 2005/2006, 31.3% or 243 (30.6% /2005) of the major trauma patients were admitted to the FMC ICU. This does not include patients re-admitted to the ICU. At ACH, 50.6% (44 patients) of major trauma admissions were admitted to the ICU (50% 2004/2005). FMC 2004/ ACH 2004/ # of admissions # of admissions Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Total ICU trauma admissions at the FMC were 313 patients. Twenty patients of the 313 ICU admissions were ICU readmissions. All unplanned ICU admissions and readmissions were reviewed as part of the trauma quality assurance process. FMC Trauma ICU admissions comprised 25.2% of the total overall ICU admissions of 1241 for the fiscal year (update for 2005/2006). The total ICU trauma admissions at the ACH were 44. In 2005/2006, there were no ICU readmissions. All ICU trauma admissions were planned as determined by the ACH Trauma Audit Committee

50 ICU TRAUMA ADMISSIONS cont. FMC - 5 Year Trend ACH - 5 Year Trend # of admissions # of admissions /02 02/03 03/04 04/05 05/06 01/02 02/03 03/04 04/05 05/06 MEDIAN ICU LOS FOR TRAUMA PATIENTS Medians provide a better evaluation of LOS for comparison purposes; averages are greatly affected by the ranges of LOS, particularly by extended LOS. FMC - 5 Year Trend ACH - 5 Year Trend # of days # of days /02 02/03 03/04 04/05 05/06 all patients 01/02 02/03 03/04 04/05 05/06 all patients All patients range days Average 8.3 Standard deviation (SD) 11.3 Comparison: 04/05 average 9.2 All patients range 1-28 days Average 4.0 Standard deviation (SD) 5.8 Comparison: 04/05 average 2.4 The median ICU LOS decreased from 5 to 4 days at the FMC ICU. Improved access and patient flow was and is a priority issue for the Calgary Health Region quality improvement initiatives. At FMC access to ICU beds has presented many challenges over the last year. In some cases, patients had to be transferred from FMC ICU to other acute care sites to accommodate the admission of the trauma patient. Processes and policies regarding inter-facility transfers between sites were well established and further developed with the introduction of the Southern Alberta Regional Coordination Centre (SARCC). In other cases the patients waited in Post Anaesthetic Recovery Room (PAAR) for an ICU bed. The Regional nodiversion policy was strictly upheld for trauma patients and included in the revised policies. The median ICU LOS at the ACH increased in 2005/2006. There were 25 patients with 1 day ICU LOS in 2004/2005. The new ACH is scheduled to open in September 2006, the number of paediatric ICU (PICU) beds will increase from 13 to 20 beds. This increase in capacity will help to improve overall access to PICU beds

51 MEDIAN HOSPITAL LENGTH OF STAY (LOS) The median hospital LOS has demonstrated little change over the past 5 years. This included the acute phase of the hospital stay at FMC, not the rehabilitation phase, which can range from days to months. FMC - 5 Year Trend ACH - 5 Year Trend # of days # of days 2 01/02 02/03 03/04 04/05 05/06 all patients 01/02 02/03 03/04 04/05 05/06 all patients All patients range days Average 13.1 Standard deviation (SD) 15.8 Comparison: 04/05 average 14.4 All patients range 1-28 days Average 4.0 Standard deviation (SD) 5.8 Comparison: 04/05 average 2.4 OUTCOMES BY AGE The literature states that, generally, outcomes for older adults (65+) or the very young trauma patient (<1) are poor. This is supported by current trauma registry statistics for the older adults (65+). In 2005/2006, there was a decrease in the percentage of older adult trauma patients (65+) who died from injuries sustained (21.5%), compared to 2004/2005 (22.9%). The % mortality rate however is highest in the older adult population. Of the younger adult age groups (< 65), 10% died (8% in 2004/2005). At ACH in 2005/2006, the 1-4 age group experienced the highest mortality (18%) with MVCs and falls as the major cause of death. In 2004/2005, the 5-9 age groups showed the highest mortality (19%) with injuries sustained from MVC contributing to their deaths. FMC 2005/2006 ACH 2005/2006 % mortality # of patients >84 < >14 % Mortality Survivors Non-survivors There was one death in the < 0-14 year age group at FMC in 2005/2006. FMC exclusions: 3 non survivors with unknown age. The ACH numbers were too small to accurately present %mortality in the same format as FMC

52 OUTCOMES BY MAJOR MECHANISM OF INJURY At the FMC, the percentage of major trauma patients who succumbed to their injuries was highest for falls (13.4%) followed by transportation (13.3%), then violence (12.1%) and lastly other mechanism of injury (12) %. Last year, violence claimed the highest percentage of lives (11.3%). At the ACH, mortality was highest in the other mechanism of injury category at 11%. This was followed by falls at 7.4%, and transportation at 7.3%. No deaths occurred in the violence category. 359 FMC 2005/ ACH 2005/2006 # of Patients # of Patients Transportat ion Falls Violence Ot her Transportation Falls Violence Other Survivors Non-s urvivors Survivors Non-survivors YEARLY OUTCOMES BY SURVIVORS/NON-SURVIVORS The mortality rate at FMC (13.1%) has increased when compared with 2004/2005 (10.9%). Mortality rate at ACH (8%) decreased from 2004/2005 (11.4%). FMC - 5 year trend ACH - 5 year trend # of Patients # of Patients /02 02/03 03/04 04/05 05/06 01/02 02/03 03/04 04/05 05/06 Survivors Non-survivors Survivors Non-s urvivors There was a 30.9% increase in adult major trauma deaths in 2005/2006 (i.e. 30 deaths) and a 43% decrease in paediatric major trauma deaths. The office of the Chief Medical Examiner (Edmonton, Alberta), Alberta Justice, provided a report for the 2004/2005 and the 2005/2006 trauma services reports. The reports indicated that there was a 10.8% increase in trauma deaths over the previous year (672 deaths) and 464 occurred outside the hospital; 312 of occurred in the City of Calgary. The number of children that died, according to the ME database, increased from 41 in 2003/2004, to 49 in 2004/2005, to 57 in 2005/2006 or a 39% increase in deaths over three years. For more information/details see the Chief Medical Examiner s Report in this document

53 OUTCOMES BY ISS As the ISS increases, the risk of mortality increases. At FMC, the ISS range showed the highest mortality rate. At ACH, the ISS range showed the highest mortality rate of 50%. There were no patients at ACH with an ISS greater than 45. FMC 2005/2006 # of patients ISS scores survivor non-survivor ACH 2005/ # of patients % Mortality Rate ISS scores survivor non-survivor

54 DISCHARGE LOCATION The majority of trauma patients from both sites were discharged home. From the documentation in the chart, it is often difficult to determine which, if any, support services may be provided at home ; therefore home with support may be under represented. The other/unknown category represents patients discharged to locations other than previously defined or for which no specific discharge location was documented in the chart. FMC 2005/2006 ACH 2005/ # of Patients # of Patients Home Rehab Acut e Care Nursing / Chronic Care Home / Support Died Ot her / Unknown Home Rehab Acute Care Home / Support Children's Aid/Foster Died Other / Unknown NOTE: The ACH does not have a dedicated rehabilitation unit; the FMC has dedicated beds. Four dedicated rehabilitation beds are planned for the new ACH site opening in Sept ISS 16 TRAUMA TOTALS In 1992, the inclusion criterion for the Trauma Registry was ISS 16. In 1993, this was revised to an ISS 12. The following graph depicts a 5-year span of patients with an ISS 16. FMC - 5 year trend ACH - 5 year trend # of Patients # of Patients /02 02/03 03/04 04/05 05/06 ISS 16 01/02 02/03 03/04 04/05 05/06 ISS 16 At FMC, there has been a 24.2% increase in the number of patients with an ISS 16 over the last 5 years (01/02-648). At the ACH there was a 20.9% decrease in 2005/2006 when compared to 2001/2002. This rise in major trauma cases has resulted in increased pressures on acute care and community resources, with demands for improvements in access to services, technology, performance and efficiency measures. Regional Trauma Services, in partnership with various acute care and community groups, plays a lead role in supporting providers to meet the challenges and ensure quality, effective care for trauma patients and their families throughout the system

55 Trauma Statistics PETER LOUGHEED CENTRE ROCKYVIEW GENERAL HOSPITAL Prepared By: Ms. Dianne Dyer, Manager Regional Trauma Services Ms. Christi Findlay, Data Analyst Regional Trauma Services Data Entry By: Ms. Sukhi Lally, Data Analyst Regional Trauma Services

56 TRAUMA SUMMARY FOR PETER LOUGHEED CENTRE (PLC) / ROCKYVIEW GENERAL HOSPITAL (RGH) Three strategies were used evaluate trauma care at the PLC/RGH sites: 1. Review of monthly injury discharge summaries prepared by Quality Safety Health Information (QSHI). Trauma patients with an Injury Severity Score (ISS) 12 were identified through chart audit. Information was then abstracted into the Trauma Registry (Trauma Registry inclusion criteria is an ISS 12 and admission to the hospital or death in the emergency department). Each site had a specific data set with performance indicators and audit filters to monitor trauma care. The review of admission lists was piloted but found to be too resource intense, with no significant difference in the identification of the major trauma population. 2. Staffs at both sites were encouraged to complete a trauma follow-up form in emergency with information on the traumatically injured patient. Forms were collected monthly. 3. System issues were referred directly to Regional Trauma Services. Once issues were identified, they were brought forward to the appropriate site trauma committees. There were two trauma committee meetings at the PLC and three at RGH in 2005/2006. If the issue required more immediate follow-up, it was addressed as soon as possible with the specific department. The following graph represents the injury population that was identified and reviewed by Trauma Services. Total Charts Reviewed per Site 2005/ PLC 314 RGH Of the 267 charts reviewed at the PLC, 192 were from the monthly injury discharge summaries and 75 were referrals from the follow-up forms or direct referral to Trauma Services. Of the 314 charts reviewed at the RGH, 263 were from the monthly injury discharge summaries and 51 were from the follow-up forms or direct referral to Trauma Services. The following graphs reflect the major trauma population (ISS 12) that was identified and reviewed by Trauma Services, based on the evaluation process list identified above. Monthly Major Trauma Totals 2005/2006 PLC RGH # of patient # of patients Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar At the PLC the largest peak was August with some smaller peaks in December and February. At RGH, peaks were seen in August, September and November. These graphs demonstrate the unpredictable nature of trauma at these sites. The numbers do not reflect the patients that arrived in ED and were transferred to the Trauma Centres

57 Yearly Major Trauma Totals PLC 2003/ / /2006 RGH 2003/ / /2006 Males/Female 2005/ Males continue to out number females at the PLC, a ratio of 2.3:1, a decrease from last year of 4:1. 6 At the RGH, females outnumber males at a ratio of 1.2:1 (1.2:1 2004/2005 as well). PLC RGH Males Females Age Distribution 2005/ Both the PLC and the RGH admitted no major trauma patients < 18 years of age At the PLC, in 2005/2006 the patient population was distributed across the age groups with some higher numbers between ages In , the majority of the population was between 45 and 84 and in the majority of the population was between 35 and 84 years (78%), > 84 PLC RGH In 2003/2004, the majority of the population at RGH was > 65 years (67.86%). This continued to be the case in 2004/2005. In 2005/2006 the higher numbers start at > 55 years of age

58 Mechanism of Injury 2005/2006 (MOI) # of patient Transportation Falls Violence Other The MOI is reported by four broad categories: transportation, falls, violence and other. These are in keeping with the focus of the Calgary Health Region s injury control initiatives. Other includes animal related incidents (e.g. riding). Falls continue to be the number one mechanism of injury at both the PLC and the RGH. PLC RGH Mode of Arrival 2005/ The majority of patients were transported by EMS to PLC and RGH this year; consistent with 2004/ EMS Private Vehicle/Walk-in Unknown PLC RGH Discharge Outcomes The majority of trauma patients from both sites were discharged home. The other/unknown category represents patients discharged to locations other than previously defined or for which no specific discharge location was documented in the chart. PLC 2005/2006 RGH 2005/ # of Patients # of Patients Home Acute Care Died Other / Unknown Home Died Rehab Other/Unknown

59 Regional Trauma & Injury Statistics Summaries FOOTHILLS MEDICAL CENTRE ALBERTA CHILDREN S HOSPITAL PETER LOUGHEED CENTRE ROCKYVIEW GENERAL HOSPITAL Prepared By: Ms. Christi Findlay, Data Analyst Regional Trauma Services Ms. Maria Vivas, Data Analyst Regional Trauma Services Reviewed By: Ms. Dianne Dyer, Manager Regional Trauma Services

60 The following table summarizes the injury data, based on injury discharge codes provided by QISI and Trauma Registry, for the fiscal year 2003/2004 vs. 2004/2005 vs. 2005/2006 (all ages combined). 2003/ / /2006 Sites Injury ISS 12 Injury ISS 12 Injury ISS 12 Discharges Discharges Discharges FMC ACH PLC RGH Total There was a 2.2% increase (170) in overall injury discharges from 2004/2005 to 2005/2006. The number of overall major trauma patients increased by 88 patients or 8.6% for all sites combined. Traumatic Injury Inpatient Summary >18 years of age by Site and Month (QSHI) # of patients Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar FMC PLC RGH Totals: FMC PLC RGH Overall Total 6840 This year there is no clear evidence of a peak in trauma injury inpatient admissions in any one specific month and/or grouping of months in the 18 year age group. It has been the past practice that, based on high trauma patient numbers, the staff resources were increased in summer months and over the Christmas season. The ability to accurately predict peaks in adult trauma patient numbers is however; becoming less reliable and accurate and therefore presents significant challenges for the manager(s) planning for quality patient care. The numbers are consistently high and impact the overall system on an on-going basis

61 Child Health Inpatient Pediatric Trauma Study: 0-17 Years of Age by Site and Month (QSHI) # of patients Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar ACH FMC PLC RGH Totals: ACH 748 PLC 66 FMC 140 RGH 35 At the PLC, there was an increase in the number of inpatients 0-17 years from 51 patients in to 66 in 2005/2006. At the RGH, there was little change in 2005/2006 from 37 in 2004/2005. At the ACH however; there was an increase in patients 0-17 years from 696 patients in 2003/2004 to 737 patients in 2004/2005 to 748 in 2005/2006. The spring/summer months were highest for ACH admissions. Child Health Inpatient Pediatric Trauma Study: Years of Age by Site and Month (QSHI) # of patients Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar ACH FMC PLC RGH Totals: ACH 121 PLC 37 FMC 131 RGH 23 At the FMC, the number of inpatients years of age decreased from 123 patients in 2003/2004, to 113 patients 2004/2005; and increased to 131 in 2005/2006. The Regional Trauma Transfer Policy mandates that major trauma patients, age > 14 years be transported to FMC site. The policy was reviewed, revised and communicated to ensure compliance with transport groups

62 Foothills Medical Centre PERFORMANCE INDICATORS Prepared by: Ms. Christi Findlay, Data Analyst Regional Trauma Services Graphs prepared by: Ms. Monica Rodriguez-Galvez, Administrative Assistant Regional Trauma Services Reviewed by: Ms. Dianne Dyer, Manager Regional Trauma Services

63 TRANSPORT SYSTEM PERFORMANCE Interhospital Transfers within Calgary (Transfers from PLC/RGH/ACH to FMC Trauma Centre) Note: These sites may have received patients from or be a primary or secondary hospital site. Peter Lougheed Centre Total Injury Discharges 2005/2006 = 1464 Was the ISS > 12 patient transferred from the PLC to the FMC trauma centre? n = all patients transferred from another hospital Indicator Yes No 2005/2006, n= /2005, n = /2004, n = /2003, n = / / / /2006 %Yes %No Rockyview General Hospital Total Injury Discharges 2005/2006 = 1855 Was the ISS > 12 patient transferred from the RGH to the FMC trauma centre? n = all patients transferred from another hospital Indicator Yes No 2005/2006, n= /2005, n = /2004, n = /2003, n = / / / /2006 %Yes %No 9.3 Alberta Children s Hospital Total Injury Discharges 2005/2006 = 748 Was the ISS > 12 patient transferred from the ACH trauma centre to the FMC trauma centre? n = all patients transferred from another hospital Indicator Yes No /2006, n = /2005, n = /2004, n = /2003, n = / / / /2006 %Yes %No

64 Foothills Medical Centre PERFORMANCE INDICATORS As part of the Regional Trauma Services quality improvement process, several 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 Southwestern Sydney Region Trauma Department, Liverpool, Australia. Other indicators were developed at FMC and ACH as site specific performance indicators. The following is a summary of these indicators at FMC for patients who meet the inclusion criteria for the Alberta Trauma Registry (patients with an ISS > 12 and who are admitted to the hospital or die in the ED at the FMC). ISS is an anatomical scoring tool that provides an overall score for patients with single system or multiple system injuries. The higher the ISS score the more severe the injury. Each performance indicator number is based on the specific determinant of the indicator within the total of 969 major trauma patients. Nurses, physicians and/or Department/Division Heads review cases of identified non-compliance to determine the need for follow-up regarding process/system issues. PRE-HOSPITAL PHASE GCS (Glasgow Coma Scale) 8 at Scene / Mechanical Airway Did the patient with a first recorded scene GCS 8 receive a mechanical airway as an intervention at the scene? Mechanical airway includes intubation (nasal and oral), cricothyroidotomy and tracheostomy. Laryngeal mask airway (LMAs) are considered a very effective airway however, not a mechanical/definitive airway. n = all patients with first recorded scene GCS 8. Indicator Yes No 2005/2006, n= /2005, n = /2004, n = /2003, n = / / / /2006 %Yes %No Of the 70 that did not receive a mechanical airway, 9 had a LMA. INTERHOSPITAL TRANSFERS outside Calgary *NEW INDICATOR* Time Spent at Sending hospital Did the patient spend < 3 hours at the sending hospital prior to transfer to FMC trauma centre? n = all patients transferred from a sending hospital outside Calgary, with a known sending hospital LOS Note: revised from < 2 hours to < 3 hours in 2004/2005 Indicator Yes No 2005/2006, n = / /2006 %Yes %No 2004/2005, n =

65 District Centre Transfers Was the patient transferred from proposed district trauma centres? n = all patients transferred from hospital outside Calgary Indicator Yes No 2005/2006, n = /2005, n = /2004, n = /2003, n = / / / /2006 %Yes %No In the Provincial Trauma Proposal (revised November, 2005) five centres were identified as proposed District Trauma Centres: Lethbridge Regional Hospital, Medicine Hat Regional Hospital, Red Deer Regional Hospital, Queen Elizabeth II Hospital, Grande Prairie, and Northern Lights Regional Hospital, Fort McMurray. The proposal work is on-going with support from Capital Health Region, the Calgary Health Region and the Alberta Centre for Injury Control and Research (ACICR). The goal of the Provincial Proposal is to develop and maintain an organised, integrated provincial trauma system that is cost effective while reducing mortality and morbidity due to injury. This model aims to get "the injured person to the right treatment at the right trauma facility in the shortest time". (Source: Provincial Trauma System: Proposal for Alberta (2001, June), Alberta Centre for Injury Control & Research, p. 1). In the proposal, each identified District Centre strives to become an accredited trauma centre by the Trauma Association of Canada, which includes the establishment of a trauma team, a trauma registry and adequate educational and equipment resources. The Tertiary Trauma Centres (Calgary/Edmonton) will provide support to the sites as required directed by a Provincial Trauma Advisory Committee. Note: Annual funding approval was received in February/2007 (prior to report release). Injury Time to Trauma Centre If the patient was transferred from a hospital outside Calgary, was it less than 4 hours from injury time to arrival at FMC Trauma Centre? The 2005/2006 data demonstrates the acute and growing need for a provincial trauma system designed to monitor and evaluate delays and ensure timely access to tertiary trauma care. n = all patients transferred from a hospital outside Calgary with a known time of injury event and known time of arrival to FMC Trauma Centre Indicator Yes No / / /2006 %Yes %No 2005/2006, n = /2005, n = /2004, n =

66 Out of Province Transfers Was the patient, a non-resident of Calgary, transferred from out of province to Calgary? Of the 72 out of province transfers (non-residents of Calgary), 66 (91.7%) were transferred from hospitals in British Columbia. There was a 63.6% increase in out-of-province transfers in 2005/ n = all patients transferred from a hospital outside of Calgary with patient home address outside of Calgary. Indicator Yes No 2005/2006, n = /2005, n = /2004, n = /2003, n = / / / /2006 %Yes %No RESUSCITATIVE PHASE Trauma Team Activations At FMC, the trauma team is activated at the discretion of the ED physician, using specific activation criteria and/or through the pre-hospital process of communication. The activation criteria are based on the Gold Book, published by the American College of Surgeons Committee on Trauma, with input from the American College of Emergency Physicians and the various providers within the trauma system. The criteria for automatic trauma team activation (TTA), (level 1), are: 1. confirmed shock, defined as BP systolic < 90 or temp < intubated patient en route or in the emergency department or patient with respiratory compromise 3. patient with a GCS < 8 4. gunshot wound to the head, neck or trunk 5. need for blood transfusion en route to hospital or in the emergency department. In cases of significant mechanism of injury or obvious significant injury to patients who do not meet these criteria, early discussion/consultation with the trauma surgeon/service and the trauma resident is recommended to ensure timely intervention. The triage nurse, the emergency physician or the nurse clinician may activate the Trauma Team prior to arrival of the patient, or upon arrival of the patient to the Trauma Centre. The second level of activation is consult only. Nurses and/or physicians review charts when the TTA criteria are met and the trauma team is not activated and/or the Trauma Team Leader response exceeds 20 minutes. Recommendations may be made for action as appropriate. The activation criteria are reviewed and may be revised if appropriate to quality care by the Adult Trauma Care Committee

67 Trauma Team Leader (TTL) Response Time Was the TTL response time < 20 minutes? n = all patients with trauma team activation and a known trauma team leader response time (excludes direct admits) Unknown trauma team response times (8) excluded from response time analysis. Indicator Yes No 2005/2006, n = /2005, n = /2004, n = /2003, n = / / / /2006 %Yes %No FMC Trauma Total Comparisons Trauma Team Activations any ISS Major Trauma Admissions with ISS >= Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar In 2005/2006 there were 353 documented trauma team activations in total, 209 patients were classified as major trauma (ISS 12). This graph represents the number of documented trauma team activations/month (any ISS) in 2005/2006 compared with the patients that qualified as ISS 12. In some months the number of patients ISS 12 is less than 50% of the number of patients that trigger a trauma team activation. Trauma experts advise that is better to over activate and err on the side of caution

68 Trauma Team Activation (TTA) Criteria TTA Criteria Met 34.9% (338) TTA Criteria Not Met 65.1% (631) Yes, TT Activated No, TT Not Activated Yes, TT Activated No, TT Not 54.4% (184) 45.6% (154) 4% (25) Activated Response Time within Response Time within 20 Minutes? 20 Minutes? Yes No Unknown Response Yes No Unknown Response 90.2% (166) 3.8% (7) Time 76% (19) 4% (1) Time Excludes direct admits In 2005/2006, of the 154 cases in which the criteria were met but the team was not activated, 64 (40.9%) were single system head injured patients. In many cases of the single system head injury the patient is referred directly to the neurosurgeon on-call and, if non-operative, the patient is admitted to the hospitalist. If the patient qualifies as major trauma (i.e. ISS > 12) the case is flagged using the Trauma Registry and reviewed. The concern with this type of direct referral is the potential for a missed injury when the focus is on a single system; the tertiary survey is a critical step in the process of assessment. GCS < 8 Mechanical Airway in ED Did the patient with a first recorded trauma centre GCS < 8 receive a mechanical airway as an intervention in the FMC ED? Mechanical airway includes intubation (oral, nasal, cricothyroidotomy and tracheostomy). n = all patients with 1 st recorded trauma centre GCS 8. Indicator Yes No 2005/2006, n = /2005, n = /2004, n = /2003, n = / / / /2006 %Yes %No

69 ED Length of Stay (LOS) Did the patient have an FMC ED length of stay < 4 hours? Median ED LOS: 5.3 hours Average ED LOS: 6.8 hours Range: 0 to 47.2 hours n = all patient seen in FMC ED with a known LOS. Indicator Yes No 2005/2006, n = /2005, n = /2004, n = /2003, n = / / / /2006 %Yes %No Joint Reduction Was the joint dislocation or fracture/dislocation reduced within 1 hour of arrival to the FMC trauma centre? *In 2005/2006, ankle dislocations were excluded from the indicator due to evidence of consistent improved compliance. In the 2006/2007, this indicator will be revised to read: If the patient has a joint dislocation was an attempt made to relocate the joint within one hour of arrival to the Trauma Centre? The focus is on rapid intervention and consultation if required n = ( ) all patients with a hip, shoulder, elbow, ankle*, wrist or knee joint dislocation with a hospital LOS 1 hour and a known reduction time. Indicator Yes No 2002/ / / /2006 %Yes %No 2005/2006, n = /2005, n = /2004, n = /2003, n = CT of the Head If the patient had a GCS < 13, was a CT of the head performed within 4 hours of arrival to the FMC trauma centre? n = all patients with a known FMC ED GCS, a known time of CT head, LOS >/= 4 hours and no head CT at sending hospital. Indicator Yes No 2005/2006, n = /2005, n = /2004, n = /2003, n = / / / /2006 %Yes %No

70 DEFINITIVE CARE PHASE Craniotomy If the patient had an epidural or subdural brain hematoma, was a craniotomy performed within 4 hours of arrival at the FMC trauma centre? Note: This indicator excludes documented subacute or chronic injuries n = all patients with epidural or subdural hematoma where operative management was the planned intervention. Indicator Yes No 2002/ / / / /2006, n = /2005, n = /2004, n = /2003, n = %Yes %No Gunshot Wound to Abdomen Was the abdominal gunshot wound managed operatively? n = all patients with abdominal gunshot wound admitted to FMC Trauma Centre. Indicator Yes No 2005/2006, n = /2005, n = /2004, n = /2003, n = / / / /2006 %Yes %No Pelvic Fracture If the patient sustained a pelvic ring fracture and was hemodynamically unstable in the emergency department, was provisional stabilization done within 12 hours of arrival to the trauma centre? Hemodynamically unstable: Systolic BP < 90 or greater than 4 units of packed red blood cells given in the first hour n = all hemodynamically unstable patients with pelvic ring fracture and provisional stabilization Indicator Yes No 2004/ / /2006, n = /2005, n = %Yes %No

71 Pelvic Fracture Did this patient (from previous indicator) have their pelvic fracture definitively repaired within 7 days of arrival to trauma centre? Excludes patients who died prior to definitive repair n = all patients with pelvic ring fracture who were hemodynamically unstable in ED, had provisional stabilization and survived at least 7 days Indicator Yes No 2005/2006, n = /2005, n = Acetabular Fracture If the patient sustained an acetabular fracture and was hemodynamically unstable in the emergency department, was provisional stabilization done within 12 hours of arrival to trauma centre? 2004/ /2006 %Yes %No 0 0 Hemodynamically unstable: SBP < 90 or greater than 4 units of packed red blood cells in the first hour n = all hemodynamically unstable patients with acetabular fracture and provisional stabilization Indicator Yes No 2005/2006, n = /2005, n = Acetabular Fracture Did this patient (from previous indicator) have their acetabular fracture definitively repaired within 7 days of arrival to trauma centre? 2004/ /2006 %Yes %No 0 0 Excludes patients who died prior to definitive repair n = all patients with acetabular fracture who were hemodynamically unstable in ED, had provisional stabilization and survived at least 7 days Indicator Yes No 2004/ / /2006, n = /2005, n = %Yes %No

72 Femur Fracture Did the patient have operative management of the femur fracture within 24 hours of arrival to FMC trauma centre? This indicator was reviewed by the Division of Orthopaedics and will remain unchanged for the 2006/2007 year. Criteria is undergoing further review. n = all patients with operative management of femur fracture. Indicator Yes No / / / / /2006, n = /2005, n = /2004, n = /2003, n = %Yes %No Open 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 FMC trauma centre? Long bones include radius, ulna, humerus, tibia, femur and fibula. This indicator was reviewed by the Division of Orthopaedics and will remain unchanged for the 2006/2007 year n = all patients with operative management of open long bone fracture. Indicator Yes No 2005/2006, n = /2005, n = /2004, n = /2003, n = / / / /2006 %Yes %No Unplanned Return to OR Did the patient have an unplanned return to the operating room within 48 hours of the initial procedure? n = all patients with at least one operating room visit. Indicator Yes No 2005/2006, n = /2005, n = /2004, n = /2003, n = / / / /2006 %Yes %No

73 Admitting Physician Was the patient admitted under a surgeon or intensivist at the FMC trauma centre? The majority of cases, determined to require review, were admissions to a Hospitalist. NOTE: Excludes patients admitted for palliative care. n = all patients admitted to FMC Trauma Centre. Indicator Yes No 2005/2006, n = /2005, n = /2004, n = /2003, n = / / / /2006 %Yes %No Delayed Diagnosis/Missed Injury Did the patient have a delayed diagnosis or missed injury diagnosed > 48 hours from arrival at the FMC trauma centre? Missed injuries: 45% extremity, 18.2% face, 13.6% abdomen, 9.1% thorax, 9.1% head and 4.5% spine. 48 hours was selected as it allows time for the comprehensive tertiary survey n = all patients admitted to FMC Trauma Centre who survived > 48 hours from arrival. Indicator Yes No / / / / /2006, n = /2005, n = /2004, n = /2003, n = %Yes %No Missed C-Spine Injury Was there a missed c-spine injury with c-spine precautions removed at the FMC trauma centre? 10.8% of the total major trauma admissions had a c-spine injury. n = all patients admitted to FMC Trauma Centre Indicator Yes No /2006, n = / / / / /2005, n = /2004, n = /2003, n = %Yes %No

74 Unplanned ICU Admission Was there an unplanned ICU trauma admissions at the FMC trauma centre? In total, there were 313 trauma patients admitted to the ICU (planned and unplanned) within an overall total of 1241 ICU admissions. Most unplanned trauma admissions were due to respiratory compromise n = all patients admitted to FMC Trauma Centre. Indicator Yes No 2005/2006, n = /2005, n = /2004, n = /2003, n = / / / /2006 %Yes %No 2.4 Unplanned ICU Readmission Did the patient have an unplanned trauma readmission to ICU at the FMC trauma centre? Most unplanned trauma readmissions were due to respiratory compromise. Of the 20 patients readmitted to ICU, 12 were unplanned, 4 were planned, and 4 were readmitted 3 times n = all patients with at least one ICU admission. Indicator Yes No 2005/2006, n = /2005, n = /2004, n = /2003, n = / / / /2006 %Yes %No Ischemic Limb Was the ischemic limb revascularized at the FMC trauma centre, within 6 hours of injury? Patient must have penetrating wound to an artery or severe fracture where the limb is pulseless. Attempts to reduce the limb have failed and the patient has gone to the OR for vascular repair (shunt, graft or amputation) n = all patients with ischemic limb, LOS 6 hours and stable enough for OR. Indicator Yes No 2005/2006, n = /2005, n = /2004, n = /2003, n = / / / /2006 %Yes %No

75 Thromboembolic (DVT) Prophylaxis Did the immobile patient receive documented thromboembolic prophylaxis within 24 hours of admission at the FMC trauma centre? Dedicated pneumatic pumps and stockings were ordered for Unit 71, the FMC Trauma Unit, to ensure prompt access to equipment. All patients receive stockings unless otherwise ordered by the physician. This indicator includes all units with trauma patients and relies heavily on nursing documentation of the intervention n = all immobile patients whose LOS 24 hours. Indicator Yes No 2005/2006, n = /2005, n = /2004, n = /2003, n = / / / /2006 %Yes %No Major Facial Fracture Did the patient receive operative management of major facial fractures (mandible, maxilla or orbit) at the FMC trauma centre, within 7 days of injury? n = all patients who have operative intervention of major facial fracture. Indicator Yes No 2005/2006, n = /2005, n = /2004, n = /2003, n = / / / /2006 %Yes %No Spinal Fracture Did the patient receive operative management of spinal fractures at the FMC trauma centre, within 7 days of injury? n = all patients who have operative intervention of spinal fracture Indicator Yes No 2005/2006, n = / / / / /2005, n = /2004, n = /2003, n = %Yes %No

76 LAPAROTOMY CATEGORIES These categories include all patients with suspected intra-abdominal injury requiring a laparotomy. Nurses and/or physicians reviewed all laparotomy cases to determine the need for follow-up regarding process/system issues. Patients were categorized based on the following criteria: Category 1: Hemorrhagic shock. Time to laparotomy < 1 hour. Patients with a blood pressure, systolic < 90 in the trauma room, confirmed, or a need for > 4 units of packed red blood cells in the first hour, for hemorrhage due to injury. Category 2: Hemodynamically stable patients requiring emergency laparotomies. Time to laparotomy < 4 hours. Patients presenting with truncal injury requiring emergency laparotomy who do not meet criteria for shock. Transfusion requirements are < 4 units in the first hour. BP systolic is > 90. Typically, these represent patients with injuries identified at the time of CT scanning. Category 3: Patients requiring delayed laparotomy. Patients for whom acute indications for emergency laparotomy were not identified at the time of initial trauma assessment and resuscitation (i.e. patients with stable visceral injury with delayed development of bleeding, or patients with occult intra-abdominal injuries, diagnosed after admission). Category 1 Laparotomies If the patient received a Category 1 laparotomy, was it performed within 1 hour of arrival to FMC trauma centre? 2004/ /2006 median time to lap: 50 min median time to lap: 59 minutes average time to lap: 91 min average time to lap: minutes range: minutes range: minutes n = all patients with Category 1 laparotomy. Of patients requiring category 1 laparotomy, and laparotomy was not performed within 1 hour of arrival to trauma centre, 50% had laparotomy within 2 hours and 25% had it performed within 3 hours. Indicator Yes No 2005/2006, n = / / /2006 %Yes %No 2004/2005, n = /2004, n = Category 2 Laparotomies If the patient received a category 2 laparotomy, was it performed within 4 hours of arrival to FMC trauma centre? 2004/ /2006 median time to lap: 171 min median time to lap: 125 minutes average time to lap: 192 min average time: minutes range: minutes range: minutes n = all patients with Category 2 laparotomy. Indicator Yes No 2005/2006, n = /2005, n = /2004, n = / / /2006 %Yes %No

77 Therapeutic Laparotomies: Category 1 If the patient required laparotomy at the FMC trauma centre, was the laparotomy therapeutic? Therapeutic laparotomy is defined as discovery of an injury that requires suturing or packing n = all patients with Category 1 laparotomy. Indicator Yes No 2005/2006, n = / / / /2005, n = /2004, n = %Yes %No Therapeutic Laparotomies: Category 2 If the patient required laparotomy at the FMC trauma centre, was the laparotomy therapeutic? Therapeutic laparotomy is defined as discovery of an injury that requires suturing or packing. n = all patients with Category 2 laparotomy. Indicator Yes No 2005/2006, n = / / / /2005, n = /2004, n = %Yes %No Therapeutic Laparotomies: Category 3 If the patient required laparotomy at the FMC trauma centre, was the laparotomy therapeutic? Therapeutic laparotomy is defined as discovery of an injury that requires suturing or packing. n = all patients with Category 3 laparotomy. Indicator Yes No 2005/2006, n = / / / /2005, n = /2004, n = %Yes %No

78 Death during First 24 Hours OUTCOMES Did the patient die within the first 24 hours of arrival to the FMC trauma centre? All death cases are reviewed by Trauma Services. Cases may be presented at the Adult Trauma Quality Improvement Committee if there are system issues/concerns for follow-up. n= all patients who die. Indicator Yes No 2005/2006, n = /2005, n = /2004, n = /2003, n = / / / /2006 %Yes %No Mortality Did the patient die at the FMC trauma centre? n = all patients arriving at FMC trauma centre. Indicator Yes No 2005/2006, n = /2005, n = /2003, n = /2002, n = / / / /2006 %Yes %No

79 TRAUMA SCORE INJURY SEVERITY SCORE (TRISS) METHODOLOGY TRISS methodology uses logistic regression to predict survival based on the Revised Trauma Score (RTS), injury severity score (ISS), mechanism of injury (blunt vs. penetrating) and patient age. Unexpected deaths are trauma patients with a predicted probability of survival of 0.5 or more that die and unexpected survivors are trauma patients with a predicted probability of survival of 0.49 or less that survive. TRISS z statistic measures the statistical significance of the difference between the actual number of survivors among a set of patients and the number of survivors expected from outcome norms. W measures the clinical significance of the differences between the actual and unexpected survivors. W is the number of survivors more than would be expected from the outcome norms per 100 patients treated. W can be calculated if the z score is greater than Due to the physiologic parameters used in the Revised Trauma Score, patients who do not have a recorded Glasgow Coma Scale (GCS) will not have a TRISS value calculated. Fiscal Year: April 1, March 31, 2006 z Score W Score Sample Size Adult Blunt Adult Penetrating Paediatric Total Subset Data: z Score W Score Sample Size Adult Blunt Adult Penetrating Paediatric Total Subset For , there were 1.69 more survivors per 100 than would have been expected from the major trauma outcome study. The Alberta Trauma Registry at FMC has 7758 major trauma patient records in total. 68.3% (5296 patients) were eligible for z and W score while 31.7% (2462) were not eligible for the following reasons: not blunt or penetrating injury, missing data required for calculation of revised trauma score (respiratory rate, systolic blood pressure, GCS). Outcome and Probability of Survival With a probability of survival > 20%, did the patient die at the FMC trauma centre? n = all patients with probability of survival valued and probability of survival > 20%. Indicator Yes No 2005/2006, n = /2005, n = /2003, n = /2002, n = / / / /2006 %Yes %No

80 Alberta Children s Hospital PERFORMANCE INDICATORS Prepared by: Ms. Maria Vivas, Data Analyst, Regional Trauma Services Reviewed by: Ms. Dianne Dyer, Manager, Regional Trauma Services

81 Alberta Children's Hospital PERFORMANCE INDICATORS As part of the Regional Trauma Services quality improvement process, several 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 FMC and the ACH as site specific performance indicators. The following is a summary of these indicators for the ACH for patients who meet the inclusion criteria for the Alberta Trauma Registry (patients with an ISS > 12, and who are admitted to the hospital or die in ED at the ACH). All cases flagged by a performance indicator or audit filter are reviewed by the ACH Trauma Audit Committee to determine appropriateness of care. *Each performance indicator number is based on the specific determinant of the indicator within the total of 87. *If the ACH Trauma Audit Committee identifies cases where there were questions, the committee generates letters to follow up on those cases. PRE-HOSPITAL PERFORMANCE INDICATORS Glasgow Coma Scale (GCS) < 8 at Scene - Mechanical Airway Did the patient have a first recorded GCS < 8 at the scene and have a mechanical airway as an intervention at the injury scene? Mechanical airway includes: oral intubation, nasal intubation, tracheostomy, and cricothyroidotomy Paediatric experts advise that it is best practice to move the injured paediatric patient from the scene quickly to acute care for intubation, if required, rather than attempt intubation at the scene. A literature review is in process at this time to identify supporting literature/research evidence. n = all patients with 1 st recorded GCS 8 at the scene. Indicator Yes No / / / /2006 %Yes %No 2005/2006, n = /2005, n = /2004, n = /2003, n =

82 ACH Transport Team Utilization Was the patient transported by the ACH Transport Team? All patients were transferred from a primary or secondary hospital. The ACH Audit Committee reviews all eligible patients not transferred by the transport team, to determine if this service would have benefited them. Follow-up includes strategies to educate and raise awareness of this valuable service and to provide instruction on how to access it. Use of the service is encouraged / / / /2006 n = all patients transferred from a primary or secondary hospital. Indicator Yes No 2005/2006, n = /2005, n = /2004, n = /2003, n = The Paediatric Transport Team %Yes %No The Alberta Children s Hospital offers a specialized Paediatric Transport Team Service, which transports critically ill or injured children from referring centers located in southern Alberta, southeastern British Columbia, and south-western Saskatchewan. The transport team travels by ambulance, helicopter or fixed-wing aircraft and provides quality paediatric critical care to the residents of these areas who do not otherwise have access to paediatric critical care specialists. Through Link Center communications, medical control and mobilisation of the team is achieved via the PICU attending physician. The team consists of one physician (ICU or ED), a respiratory therapist (RT), and an ACH ICU registered nurse (RN). A specialized paediatric RN/RT team is currently being developed which will address shortages in MD coverage. This new physician less transport program will be implemented within the next fiscal year. Ongoing review and quality assurance of all paediatric transport occurs with monthly transport team meetings. INTERHOSPITAL TRANSFER OUTSIDE CALGARY Time Spent at Sending Hospital Outside Calgary Did the patient spend < 2 hours at the sending hospital outside of Calgary, prior to transfer to ACH trauma centre? This indicator combines the primary and secondary hospitals into the sending hospital. n = all patients transferred from a sending hospital outside Calgary, with a known sending hospital LOS. Indicator Yes No 2005/2006, n = /2005, n = / / /2006 %Yes %No 2003/2004, n =

83 Known Injury Time to Trauma Centre Did the patient arrive at a trauma centre < 4 hours from the time of injury? Trauma Centre is defined as ACH, FMC, or Stollery Hospital in Edmonton. Out of the 41 patient transfers, 2 patients were transferred from within Calgary and 11 patients had unknown time of injury, resulting in a total (n) of 28 patients for this indicator. Trauma Services has been invited to meet with Calgary Emergency Services to discuss their new electronic charting format. Discussions regarding documentation of time of injury will be included. n = all patients transferred from a hospital outside Calgary with a known time of injury and known time of arrival. Indicator Yes No 2005/2006, n = /2005, n = /2004, n = /2003, n = / / / /2006 %Yes %No A significant change was noted with this performance indicator. Although fewer patient transfers occurred in , a higher percentage of patients were spending more time at the referral centers. Although many factors contribute to delays, it was discovered that most were related to challenges in mobilising transfer of patients from rural health centers. Any delays that are considered unacceptable by the ACH Trauma Audit Committee are reviewed and appropriately followed up. This trend will continue to be followed and assessed by the ACH Trauma Audit Committee. RESUSCITATIVE PHASE Major Trauma Team Activation and # of Activation Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 2004/ /2006 At the Alberta Children s Hospital, activation of the trauma team (Code 77) is initiated through the ED at the discretion of the ED physician and based on criteria. The criteria used for Code 77 activation are currently under review and should be updated within the next fiscal year. 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

84 ED Length of Stay (LOS) Did the patient have an ACH ED length of stay < 4 hours at the ACH trauma centre? Median = 2.95 hours Average = 3.67 hours Range: Minimum = 38 minutes, Maximum = hours n = all patients seen in ACH ED with a known ED LOS. Direct admissions are excluded. Indicator Yes No 2005/2006, n = /2005, n = /2004, n = /2003, n = / / / /2006 %Yes %No GCS < 8 at ACH ED - Mechanical Airway Did the patient with a first recorded trauma centre GCS < 8 receive a mechanical airway as an intervention in the ACH ED? n = all patients with 1 st recorded trauma centre GCS 8. Indicator Yes No 2005/2006, n = /2005, n = /2004, n = /2003, n = / / / /2006 %Yes %No DEFINITIVE CARE Admitting Physician Was the patient admitted to a surgeon or an intensivist at the ACH trauma centre? 19 patients were admitted to the hospital-based paediatricians n = all patients admitted to ACH Trauma Centre. One ED death was excluded. Indicator Yes No 2005/2006, n = /2005, n = /2004, n = /2003, n = / / / /2006 %Yes %No

85 CT of the Head Did the patient with a GCS < 12 receive a CT of the head at a sending hospital or within 4 hours of arrival at the ACH trauma centre? n = all patients with a known ED GCS and a known time of CT head. Patients who arrive intubated to ACH are excluded. Indicator Yes No 2005/2006, n = /2005, n = /2004, n = /2003, n = / / / /2006 %Yes %No Craniotomy If the patient had an epidural or subdural brain hematoma, was a craniotomy performed within 4 hours of arrival at ACH trauma centre? n = all patients with epidural or subdural hematoma where operative management was the planned intervention. Indicator Yes No 2005/2006, n = /2005, n = /2004, n = /2003, n = / / / /2006 %Yes %No Femur Fracture Did the patient have operative management of the femur fracture within 24 hours of arrival at ACH trauma centre? n = all patients requiring operative management of femur fracture. Indicator Yes No 2005/2006, n = /2005, n = /2004, n = /2003, n = / / / /2006 %Yes %No

86 Open 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. n = all patients requiring operative management of open fracture where grade of fracture is known. Indicator Yes No / / / / /2006, n = /2005, n = /2004, n = /2003, n = Major Facial Fractures Did the patient with a facial fracture go to the operating room at ACH trauma centre within 7 days of injury? %Yes %No 33.3 n = all patients requiring operative management of major facial fractures. Indicator Yes No 2005/2006, n = /2005, n = /2004, n = /2003, n = / / / /2006 %Yes %No Unplanned Return to OR Did the patient have an unplanned return to the operating room at the ACH trauma centre? n = all patients with at least one operating room visit. Indicator Yes No 2005/2006, n = /2005, n = /2004, n = /2003, n = / / / /2006 %Yes %No

87 Delayed Diagnosis/Missed Injury Did the patient have a delayed diagnosis or missed injury at the ACH trauma centre? n = all patients admitted to ACH Trauma Centre. One ED death was excluded. Indicator Yes No 2005/2006, n = /2005, n = /2004, n = /2003, n = / / / /2006 %Yes %No 1 Missed C-spine Injury Did the patient have a missed c-spine injury with spinal precautions removed at the ACH trauma centre? n = all patients admitted to ACH Trauma Centre. One ED death was excluded. Indicator Yes No 2005/2006, n = /2005, n = /2004, n = /2003, n = / / / /2006 %Yes %No Unplanned ICU Admission Did the patient have an unplanned admission to ICU at the ACH trauma centre? n = all patients admitted to ACH Trauma Centre. One ED death was excluded. Indicator Yes No 2005/2006, n = /2005, n = /2004, n = /2003, n = / / / /2006 %Yes %No

88 Unplanned ICU Readmission Did the patient have an unplanned readmission to ICU at the ACH trauma centre? There were no readmissions to ICU for the major trauma patients this year. n = all patients with at least one ICU admission. Indicator Yes No /2006, n = / / / / /2005, n = /2004, n = /2003, n = %Yes %No OUTCOMES Death During First 24 Hours Did the patient die within the first 24 hours of admission to the ACH trauma centre? n = all patients who died. Indicator Yes No 2005/2006, n = /2005, n = /2004, n = /2003, n = / / / /2006 %Yes %No Mortality Did the patient die? n = all trauma patients arriving at ACH trauma centre. Indicator Yes No 2005/2006, n = /2005, n = /2004, n = /2003, n = / / / /2006 %Yes %No

89 TRAUMA SCORE INJURY SEVERITY SCORE (TRISS) METHODOLOGY TRISS methodology uses logistic regression to predict survival based on the Revised Trauma Score (RTS), injury severity score (ISS), mechanism of injury (blunt vs. penetrating) and patient age. Unexpected deaths are trauma patients with a predicted probability of survival of 0.5 or more that die and unexpected survivors are trauma patients with a predicted probability of survival of 0.49 or less that survive. TRISS z statistic measures the statistical significance of the difference between the actual number of survivors among a set of patients and the number of survivors expected from outcome norms. W measures the clinical significance of the differences between the actual and unexpected survivors. W is the number of survivors more than would be expected from the outcome norms per 100 patients treated. W can be calculated if the z score is greater than Due to the physiologic parameters used in the Revised Trauma Score, patients who do not have a recorded Glasgow Coma Scale (GCS) will not have a TRISS value calculated. ACH Z and W Score ( Adult indicates > 15 years of age) Fiscal Year: April 1, March 31, 2006 z Score W Score Sample Size Adult Blunt Adult Penetrating Paediatric Total Subset The z score is not statistically significant due to low patient numbers; therefore, the W score cannot be calculated. Data: z Score W Score Sample Size Adult Blunt Adult Penetrating Paediatric Total Subset For , there were 2.82 more survivors per 100 than would have been expected from the major trauma outcome study

90 Outcome and Probability of Survival Did the patient with a probability of survival > 20% die at the ACH trauma centre? Note: None of the deaths have a valued TRISS score. n = all patients with probability of survival valued and probability of survival > 20%. Indicator Yes No 2005/2006, n = /2005, n = /2004, n = /2003, n = / / / /2006 %Yes %No The Alberta Trauma Registry at ACH has 1003 patient records in total ( ). 62% (618 patients) were eligible for z and W score while 38% (385 patients) were not eligible for the following reasons: not blunt or penetrating injury, missing data such as respiratory rate, systolic blood pressure, GCS, (components of the revised trauma score)

91 The City of Calgary Emergency Medical Services Trauma Report April 1 st, 2005 to March 31 st, 2006

92 INTRODUCTION The City of Calgary Emergency Medical Services (Calgary EMS) is committed to the highest levels of patient care. To that end it regularly reviews the care that it provides to the community, including those that suffer traumatic injury. Calgary EMS is a municipally operated single tiered Advanced Life Support ambulance service that is responsible for responding to all 911 calls within The City of Calgary municipal boundary, Town of Chestermere, and Tsuu T ina Nation. It operates a total of 47 emergency vehicles at peak times, which are deployed from 28 EMS stations located throughout the city. This report includes a descriptive analysis of traumatically injured patients responded to by Calgary EMS (Section 1) and a focused audit of major trauma patients not transported to the designated trauma centres (Section 2). Major Trauma: A Pre-Hospital Index of 4. Minor Trauma: A Pre-Hospital Index of 3. See Appendix A Pre- Hospital Index. SECTION 1: DESCRIPTIVE ANALYSIS OF TRAUMATICALLY INJURED PATIENTS RESPONDED TO BY CALGARY EMS Background In addition to providing pre-hospital care and transport of the sick and injured, Calgary EMS actively communicates with the community through a dedicated Public Education Officer (PEO). A key mandate of the PEO is supporting the prevention of disease and injury through public education. Descriptive analyses are important background information to create key messaging and target specific sub-populations, both for public education and response strategies. Total Events N = 81,460 Methodology Data from April 1 st, 2005 to March 31 st, 2006 stored in two primary tables were downloaded from the Calgary EMS Computer Aided Dispatch database into Microsoft Access. Primary tables were merged using two key linkage variables and results downloaded to STATA (v. 9.2, STATA Corporation, College Station, Texas) for analysis. Minor and Major Trauma Events n = 15,118 (19%) Major Trauma Events 991 (7%) Figure 1: Population and Sample

93 Results A total of 81,460 unique events were recorded in this database. A total of 15,118 unique events (19%) yielded at least one assessment on a patient meeting either major or minor trauma criteria; of these events 991 unique events (7%) yielded at least one assessment on a patient meeting major trauma criteria (Figure 1). A total of 959 events recorded the age of the patient. The mean age of patients assessed with major trauma was 39.0 years (SD=21.2 years). The majority of patients assessed were adults between the ages of 25 and 64 (Figure 2). The majority of patients are male (70.8%). Patient Diagnostic Code (PDC): A proprietary system used by Calgary EMS to categorize the type of trauma or medical condition. The PDC is determined by the attending Paramedic upon completion of the call. Figure 2: Proportion of Major Trauma Patient Age Categories (n=959). Young Adults (16-24) 27.3% Children (1-15) 4.6% Infants (< 1) 0.3% Seniors ( 65) 15.4% Adults (25-64) 52.3% The most common dispatch codes for major trauma were Traffic/ Transportation Accident (36.0%), Falls (16.6%), and Stab / Gunshot / Penetrating Trauma (10.5%) (Table 1). Table 1: Top Six Dispatch Codes. Dispatch Code Frequency (%) Traffic/Transportation Accident 375 (36.0%) Fall 173 (16.6%) Stab/Gunshot/Penetrating Trauma 109 (10.5%) Assault/Sexual Assault 74 (7.1%) Traumatic Injuries (Specific) 74 (7.1%) Unknown Problem (Man Down) 44 (4.2%) Dispatch Code: A standardized code used by EMS dispatch to categorize the nature and seriousness of an event (Medical Priority Dispatch System )

94 There are a total of 10 unique Patient Diagnostic Codes (PDCs) that were categorized as major trauma. The most common major trauma PDCs were Motor Vehicle Collision (MVC) (27.6%), Fall (21.9%), and Stabbing (11.1%)(Table 2). Patient Diagnostic Code (PDC): A proprietary system used by CalgaryEMS to categorize the type of trauma or medical condition. The PDC is determined by the attending Paramedic upon completion of the call. Table 2: Frequency of Major Trauma Patient Diagnostic Codes (PDCs). PDC Frequency (%) Motor Vehicle Collision 287 (27.6%) Fall 228 (21.9%) Stabbing 116 (11.1%) Assault/Blunt Trauma 112 (10.8%) Struck by Vehicle 72 (6.9%) Pediatric 14 Years (Major) 70 (6.7%) Other 54 (5.2%) Traumatic Arrest Resuscitation Attempted 46 (4.4%) Motor Bike Collision 33 (3.2%) Gunshot 23 (2.2%) The age and gender results suggest that a sizeable proportion of patients are adult and male. When patients are stratified by gender and age category, the proportion of children, young adult, and adult males are greater than the crude measurement of 70.5% (75.0%, 78.9%, and 73.9% respectively). Females were below the crude measure of 29.5% in all categories except infants* and seniors (66.7% and 56.5% respectively) (Figure 3). These data suggest that males account for a higher proportion of patient assessments at a generally younger age than females. Proportion of Patient Assessments 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 66.7% 33.3% Infants (< 1) n=3 25.0% 75.0% Children (1-15) n=44 Female 21.1% 78.9% Young Adults (16-24) n=261 Male 26.1% 73.9% Adults (25-64) n= % 43.5% Seniors ( 65) n=147 Crude 70.5% 29.5% Age Category Figure 3: Crude Proportion of Trauma Patients by Gender, and Proportion of Trauma Patients Stratified by Age and Gender (n=957). Discussion and Limitations The proportion of events that record a trauma PDC is less than 20% of all annual events. This estimate is more than likely low, as patients are assigned a single diagnostic code, not secondary or tertiary codes. A fall, for example, that may have been caused by a syncopal episode may be recorded with a syncope PDC, not a trauma PDC. Therefore trauma injuries that may have occurred due to a medical etiology may not be included in this report, resulting in an underestimate of the true prevalence of traumatic injury in the Calgary EMS patient population

95 It is possible that there is a variation in the application of PHI criteria amongst Calgary EMS staff, and therefore patients may be classified as major trauma even though the PHI is less than or equal to three. Further assessment is required to determine if the 991 events that recorded a major trauma PDC may be an overestimate. Proportion of Patient Assessments 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 66.7% 33.3% Infants (< 1) n=3 25.0% 75.0% Children (1-15) n=44 Female 21.1% 78.9% Young Adults (16-24) n=261 Male 26.1% 73.9% Adults (25-64) n= % 43.5% Seniors ( 65) n=147 Crude 70.5% 29.5% Age Category Figure 3: Crude Proportion of Trauma Patients by Gender, and Proportion of Trauma Patients Stratified by Age and Gender (n=957). Dispatch codes can be regarded as what the public perceive is the reason for calling an ambulance. PDCs can be regarded as what the attending Paramedic has determined to be the nature of the patient condition. It is interesting to note that the top three dispatch and PDCs describe the same mechanism of injury. Moreover the difference between the cumulative percentage of the top three dispatch codes for patients classified as major trauma (63.1%) and the top three PDCs that the Paramedic recorded for major trauma as the provisional diagnosis (60.6%) is less than 3%. This suggests that EMS callers for major trauma are correct with respect to the mechanism of injury the majority of the time. When dispatch code is stratified by gender, the top two codes are similar, but the third is different. Calgary EMS is called out for a greater proportion of female patients described as an Assault/Sexual assault, and a greater proportion of male patients described as a Stab/Gunshot/Penetrating trauma. This difference is also noted when PDC is stratified by gender. These data suggest that the type of physical injury that is inflicted on major trauma patients is not exactly the same for females and males. When age is stratified by dispatch code and PDC, common age specific mechanisms are identified. Calgary EMS is predominantly called to infants due to falls and unknown problems, children due to MVCs and falls, young adults due to MVCs and stabbings, adults due to MVCs and falls, and seniors due to falls and MVCs. These data suggest that: MVCs appear to affect most age groups except infants; young adults are affected by stabbings; and infants* and seniors are primarily affected by falls. *N.B. Infant category n=3-77 -

96 Conclusions The prevalence of major and minor traumatic injury in the Calgary EMS patient population, when compared to other types of clinical conditions, is sizeable and may be underestimated. Care strategies such as Medical Control Protocols, and continuing medical education should focus on the assessment and treatment of falls in the young and old, MVC specific injuries in all age categories, and stabbings in young adults. On-going public continuing education programs should be focused on the reduction of the aforementioned injuries with a particular focus on males between the ages of 16 and 64 years. SECTION 2: FOCUSED AUDIT OF MAJOR TRAUMA PATIENTS NOT TRANSPORTED TO THE DESIGNATED TRAUMA CENTRES. Background In the Calgary Health Region certain medical conditions and injuries must be transported to specialized acute care facilities. To that end, Calgary EMS Paramedics adhere to a Hospital Destination Policy that describes the optimal destination for specific clinical presentations. The decision to adhere to this policy, however, remains with the Crew Chief Paramedic, as there may be situations that are encountered which are not explicitly covered by the policy. The Hospital Destination Policy mandates that all patients who are considered a major trauma by mechanism of injury (MOI) must be transported to Foothills Hospital (FHH) if greater than or equal to 16 years old, or Alberta Children s Hospital (ACH) if less than or equal to 15 years old (Appendix B). Data reported in the 2004/2005 Regional Trauma Services Annual Report suggests that there were 61 instances where patients who were subsequently found to have an Injury Severity Score (ISS) of greater than or equal to 12 were transported to a facility other than FHH and subsequently transferred. Inappropriate transport destination can cause delays in definitive patient care and may affect patient outcome. It stands to reason that adherence to the Calgary EMS Hospital Destination Policy should be reviewed. To appropriately assess this policy a broad approach should be taken that includes the accuracy of the trauma centre transport criteria, the level of adherence to the criteria, and a qualitative exploration underlying the rationale for noncompliance; this broad approach, however, is beyond the scope of this audit. This audit will assess the appropriateness of the transport destination in patients documented as major trauma and not transported to the designated trauma centre. Methodology All 15,118 events from the above database described in Section 1 that produced a patient classified as major trauma, but transported to an acute care facility other than FHH or ACH, were identified. Corresponding Patient Care Records (PCRs) were collected. A registered Emergency Medical Technologist Paramedic (EMT-P) reviewed all events to determine the accuracy of the major trauma classification and appropriateness of the transport decision based on documented mechanism of injury, clinical presentation, vital sign stability, and age

97 Results A total of 258 unique events were identified where a Calgary EMS Unit transported a patient classified as a major trauma to a CHR facility other than the FHH or ACH; 34 patients were retrospectively identified as meeting major trauma classification; and six patients were further retrospectively identified as being transported to an inappropriate destination based on the aforementioned criteria. The mean age of the six patients transported to an inappropriate destination was 46 years. The ages ranged from 33 to 60 years. Discussion and Limitations Of the patients that were identified in the audit as meeting major trauma classification, six were inappropriately transported to an acute care facility other than the trauma centre. None of the six patients had a compromised airway or other justification (i.e. time dependent treatment that the Paramedic could not provide) for the transport decision. Five of these patients had documented vitals that were considered stable by the reviewing EMT-P. These data suggest that six of 34 patients from this sample (18%) with a significant trauma mechanism and signs and symptoms suggestive of injury from the mechanism were not transported to the trauma centre. This may be due to the inherently stable vital signs that were recorded for five of the six patients. The age of the six patients suggest that our paediatric and elderly populations are being transported to the appropriate facility. Several limitations exist for this audit. Not all events that may have produced a major trauma patient were likely included in this sample due to challenges in collecting data in the pre-hospital environment. The definition of major trauma used by the Calgary Health Region (e.g. ISS 12) may not be the clinical equivalent of the Calgary EMS definition of major trauma (e.g. PHI 4). The PCR reviewer was not blinded to study purpose or paramedic crew attending the patient. There may be other factors that influence a paramedic s hospital transport destination decision than solely MOI, clinical presentation, vital sign stability, and age (e.g. geographic proximity to the trauma centre, hospital wait time etc.). When actively involved in providing patient care, paramedics chart patient information at the termination of the call; this may affect the accuracy of data from PCRs. No outcome data were included in this audit and so the clinical effect of inappropriate transport destination is unknown. Conclusions On-going Paramedic continuing education programs and focused quality assurance audits may decrease the proportion of major trauma patients who are not transported to the appropriate facility. Further assessment should associate outcome measures with MOI and transport destination choice. Moreover a qualitative approach may provide useful insight into the rationale behind hospital destination decision making

98 Appendix A: Pre-Hospital Index COMPONENTS VALUE SCORE BLOOD PRESSURE > PULSE > < 50 5 RESPIRATIONS Normal 0 Laboured 3 < 10 min 5 CONSCIOUSNESS Normal 0 Confused/Combative 3 No Intelligible Words 5 MECHANISM OF INJURY 4 a) MVC: Pt ejection/rollover with unbelted passengers. b) MVC: Death of other occupant in same vehicle. c) MVC: Steering wheel deformity or interior intrusion > 50 cm (> 20 inches). d) Pedestrian/cyclist struck at velocity > 15 km/hr. e) Falls > 5 meters (15 feet). f) Penetrating injuries to Head, Neck, Chest, Abdomen or Groin. g) Motorcycle victims ejected at > 30 km/hr. h) Suspected Spinal Injuries with sensory/motor changes. i) Critical burns (as per burn algorithm). j) Crush injury to abdomen/thorax. TOTAL SCORE

99 Appendix B: Hospital Destination Policy CALL TYPE 1. Paediatric (< 15 years): serious or life-threatening condition D9 Exception: inability to control airway D4, D5, D7, D9 2. Major trauma Adult (see *) D4 3. Neuro trauma (head injury): regardless of PHI, suspected head injury with ALOC (use D4 AVPU**) 4. Neuro trauma (spinal injury): regardless of PHI, traumatic mechanism of injury to D4 cervical, thoracic, or lumbar spine with subjective or objective findings of cord injury 5. Headache: sudden severe headache with no past history of headaches with or without D4 neurologic findings 6. Sudden LOC with neurologic findings D4 7. Stroke: onset of neurologic deficits < 6 hours D4 8. Sexual assault or suspected sexual assault (age 14 yrs) D7 9. Obstetrical patients: D4, D5, D7 Stable or unstable (< 20 weeks or > 32 weeks) D4, D5, D7, D9 Stable or unstable (20 to 32 weeks) D4 Trauma - PHI 4 D4 10. When geoposts not covered, stable patients transported at crew chief s discretion D4, D5, D7, D9 11. Minor trauma or medical patient with no admission required transported at crew chief s discretion D4, D5, D7, D9 12. Burns Airway compromise D4, D5, D7, D9 Adult Critical Burn D4 Paediatric Critical Burn D9 *Triage major trauma for pediatrics and adults by mechanism of injury on the PHI guide **AVPU = Patient s best response: Alert, Verbal Stimuli, Painful Stimuli, Unresponsive If in doubt, PATCH AVOIDANCE No ambulances to the requesting facility other than destination policy patients. Judgement is exercised by Crew Chief, and transports are avoided if no negative impact is anticipated to the patient s condition or to EMS response status. The Deputy Chief of Operations is to be notified. FULL DIVERSIONS No ambulances, including destination policy patients, to requesting facility unless it is unsafe to transport a critically ill patient to another facility. All resources in the ED are beyond capacity. The Deputy Chief of Operations, the Chief, & the Medical Director are to be notified

100 SHOCK TRAUMA AIR RESCUE SOCIETY (STARS) REPORT Prepared by: Michael J. Betzner MD FRCPC Senior Medical Director STARS Emergency Physician, CHR Matthew Pittet STARS data analyst

101 Shock Trauma Air Rescue Society (STARS) The Alberta Shock Trauma Air Rescue Society (STARS) provides critical care level rotary wing transport for trauma patients throughout Alberta and southeastern BC. Two pilots, a paramedic and a nurse are ready 24 hours a day, seven days a week at both bases to provide care and transport to critically ill and injured patients. A referral emergency physician accompanies patients on the helicopter on about 25% of the missions and is available and provides online medical supervision and control throughout all missions. STARS is fully Accredited through the Commission on Accreditation of Medical Transport Systems (CAMTS). The STARS Emergency Link Centre (ELC) is an advanced 24-hour communications centre providing one-call access to a variety of resources. Around the province, the ELC plays several important roles. These roles range from receiving the first call for help from an organization or individual, to being called by a partner in the Chain of Survival for assistance with an emergency. In all cases, the ELC's primary job is to connect all of the emergency and medical services into a single conversation to determine the most effective medical response for the patient and the particular situation. This includes the immediate coordination of medical advice and transportation as required (regardless of whether rotary resources are used for any particular mission). This "One Call Does it All" is being used by the Calgary Health Region's Rapid Access Line in Calgary providing physicians from rural communities with quick access to patient referral and specialist advice in affiliation with the ELC. In the past year, the communication facilitation available within the ELC, has been further complemented by an excellent working and logistical arrangement with SARCC (Southern Alberta Regional Coordination Centre); a Calgary Health Region referral, transport, and bed utilization communication service. SARCC helps to make sure patients and consultants are linked together in a fashion that maximizes utilization of available operating room, bed, and critical care resources. This information is now immediately available to assist STARS Referral Emergency Physicians in making sure patients are transported to the facility best able to look after them. This has been a very positive development within our health region. The STARS Quality Management Program (medical component) includes rigorous review of patient care records for appropriateness of patient care and documentation including secondary screens of any patient transport which involves airway management, blood administration, high risk obstetrics, pediatric patients, patients who arrest while in the care of STARS, or does not meet the utilization review criteria. All transports are monitored for adherence to response time thresholds. Any event, which meets the criteria in the risk analysis template for moderate to high risk events, undergoes a Sentinel Event Review. The STARS Human Patient Simulator (HPS) Program is the first mobile program of its kind in North America. The HPS is a dynamic, interactive, computerized mannequin. It is used for very specific, guided, intensive contact and analysis of Advanced Medical Care (AMC) critical thinking skills. The HPS mannequin simulates complex medical and traumatic problems over and over again, offering medical personnel an opportunity to test and practice their reactions and skills leading to a high degree of familiarity and confidence. In addition, patient care scenarios in our aircraft mock-up enhance the experience and better prepare our AMC for actual air medical transport events. Our mobile program also allows us to deliver advanced medical care training to rural health providers that use our services. It is an excellent means of ensuring our teams work towards the common goal of superb patient care

102 STARS transports trauma patients based on standards and utilization guidelines arrived upon by local consensus and research. All major trauma patients are taken to the Foothills Hospital Medical Centre or the Alberta Children s Hospital depending on the age of the patient. One primary response aircraft is based in both Calgary and Edmonton with three back up helicopters available for maintenance periods. We are currently in the process of staffing and opening a new base in Grande Prairie, which we anticipate will be operational during daytime hours in November This base will allow us to extend our reach into areas of northern Alberta and northeastern BC that are very remote and difficult to reach presently. The activity in Alberta s oil patch both at the work sites themselves as well as on the highways exposes workers at times to significant trauma. It is our hope that improving access and transport in these regions will prove of benefit. Response time thresholds are as follows: Scene Response - 8 minutes from dispatch to launch for scene calls (up to 12 minutes if extra fuel or supplies are required for longer scene response). Interfacility Transport - 10 minutes from dispatch to launch (up to 15 minutes for weather checks, fuelling or addition of supplies). Interfacility Transport with Physician 20 minutes from dispatch to launch. We reach these thresholds more than 80% of the time. The most common reasons for delays include difficulties associated with weather, delays related to finishing with another recent mission, and delays inherent to the vital physician-to-physician consultation process. The following graphs provide a breakdown of our trauma related activities over the past year. Approximately 43% of our overall trauma related calls are direct to the trauma scene. The rest represent interfacility transports

103 - 84 -

104 As is evident in the graphical representations, traffic accidents, wilderness and recreation activities, and falls continue to be significant mechanisms of trauma in our society. Continued education of the public in the prevention of injuries of this nature is warranted

105 JUSTICE Report Office of the Chief Medical Examiner Edmonton, Alberta Prepared by: Kim Borden Research Officer Office of the Chief Medical Examiner Calgary & South Rural Trauma Deaths Updated with 2005/2006 data on January 11, 2007 Reviewed by: Dianne Dyer, Regional Manager, Trauma Services Dr. Kent Ranson, Regional Research Coordinator

106 Report: Office of the Chief Medical Examiner (OCME) The OCME is managed from two regional offices one located in Edmonton and the other in Calgary. The Edmonton office administers all investigations in the northern part of the province, while the Calgary office administers the geographic area south of a line extending from Jasper to Hobbema and down to Provost. This report provides data related to trauma deaths for the Calgary and South rural areas. The MEDIC database is designed to collect location information on place of injury, circumstances of the death as well as place of death. Traumatic injury deaths include: - Suicides - Homicides - Unintentional intent - Undetermined intent Excludes: natural causes of death. Definitions: Suicide: Death from intentional, self-inflicted injury; includes poisonings except those that are "unclassified"; the majority of the poisonings are unclassified. Homicide: Death purposefully inflicted by other persons without regard to culpability; fatal injuries inflicted by another with the intent to injure or kill by any means, including child battering or other maltreatment, and criminal neglect (e.g. abandonment of children or other helpless persons, the death of an assailant killed in a pursuit by police is homicide). Unclassified: Death in which evidence of alcoholism or any drug misuse is a direct part of the primary medical cause of death; as stated in Part I of the Medical Certificate of Death. Undetermined: (a) The medical cause of death is unknown (the cause is anatomically and toxicologically unascertainable) or (b) It is not known if the death was unintentional intent, suicidal, or homicidal, that is there is not enough information to determine the manner of death (e.g. a self inflicted gun-shot wound while hunting may be unknown if it was unintentional intent or suicidal in manner). Unintentional intent: deaths due to unintentional or unexpected injury, including death due to external causes including environmental factors ('act of God') and other misadventures. Children: less than 18 years of age Note: 60% of the deaths that involve notification to a medical examiner in a year are due to natural causes. All unnatural, unexpected or unexplained deaths in Alberta are investigated by a medical examiner as stated in the Fatality Inquiries Act. If a person dies in hospital, under circumstances or manner of death, which would meet the criteria for a medical examiners investigation, the case is included in the database. In the case of a sudden death of an infant, a full autopsy would be performed. Regardless of whether an external exam or autopsy is completed, the case is included as a medical examiner s case. If a person is transported to a facility; the place of death is the facility and if the person is determined to have died and is not transported to a facility then the cases is considered death at the scene or enroute

107 The Office of the Chief Medical Examiner must be notified when a death is: 1. An unexplained natural death, 2. An unexpected natural death, when the decedent appeared to be in good health, 3. A natural death where the decedent did not have a physician or had not been seen by a physician within the last 14 days, 4. A death that occurs during an operative procedure or within 10 days of an operative procedure, 5. A violent or unnatural death, 6. A death which is alleged to be a result of negligence, 7. A death in custody, 8. A death of an involuntary patient or "ward" of the government, and 9. A maternal death. If a death occurs unexpectedly at home the local police department should be called. The police will contact the Office of the Chief Medical Examiner. When a death occurs suddenly or cannot be explained, the Office of the Chief Medical Examiner conducts an investigation. All such deaths in Alberta are investigated under the authority of the Fatality Inquiries Act. The investigation is held to determine: Who died? Where did they die? When did they die? Why did they die? How did they die? In some cases, a public fatality inquiry is held and recommendations are made to help prevent similar deaths. Between April 1 st 2003 and March 31 st 2004 there were 602 deaths in the Calgary and South Rural region that match the criteria for trauma, of those deaths 291 occurred in the City of Calgary. Females accounted for 27% of all trauma deaths (163). 439 of the deaths occurred outside of a hospital setting (i.e. at the scene or enroute) 41 of the deaths were children aged < 18 years at the time of their death and greater than one-third of the deaths of children occurred in hospital (37%, or 15 cases). Among pediatric trauma deaths in 2003/04, 7 of the children died at the Alberta Children s Hospital, and 4 at the Foothills Hospital, the remaining 4 deaths were divided between 4 other hospitals, outside the city of Calgary. Manner of Death All Trauma Deaths (Calgary and South Rural) Pediatric Trauma Deaths Only (Calgary & South Rural) Unintentional Intent Injury/Undetermined Intent 18 0 Homicide 34 7 Suicide Total Between April 1 st 2004 and March 31 st 2005 there were 606 deaths (602:2003/2004) in the Calgary and South Rural region that appeared to match the criteria for trauma, of the deaths 247 (290:2003/2004) occurred in the City of Calgary. Females accounted for 28% of all trauma deaths (168)

108 416 of the deaths occurred outside of a hospital setting (i.e. at the scene, or enroute). A decrease of 5.5% over the previous year. 49 of the deaths were children aged < 18 years at the time of their death, occurred in hospital (41%, or 20 cases) In 2004/05 10 of the children died at the ACH, 4 at the Foothills and the remaining 6 at 5 other hospitals outside the city of Calgary. Manner of Death All Trauma Deaths (Calgary and South Rural) Paediatric Trauma Deaths Only (Calgary & South Rural) Accidental Injury/Undetermined Intent 12 3 Homicide 27 5 Suicide Pending* 4 0 Total *Pending cases are cases that are not closed at time of this report. Between April 1 st 2005 and March 31 st 2006 there were 672 deaths in the Calgary and South Rural region that appeared to match the criteria for trauma (10.8% increase over 2004/2005), of the deaths 312 of occurred in the City of Calgary. Females accounted for 28% of all trauma deaths (185). 464 (nearly 70%) of the deaths occurred outside of a hospital setting (i.e. at the scene, or enroute) 57 of the deaths were children aged < 18 years at the time of their death. Of these deaths, 23 occurred in hospital (40) In 2005/06 seven of the children died at the ACH, six at the Foothills, two at the PLC, two at the Rockyview and the remaining 6 at 4 other hospitals outside the city of Calgary. Manner of Death All Trauma Deaths (Calgary and South Rural) Paediatric Trauma Deaths Only (Calgary & South Rural) Accidental Injury/Undetermined Intent 15 1 Homicide 38 3 Suicide Total

109 Total Deaths/Year 672 # of patients / / Deaths per year Number of patients Adults Children / / /2006 There was an 11.6% increase over 3 years. The number of children that died increased from 41 in 2003/2004, to 49 in 2004/2005, to 57 in 2005/2006. There was a 39% increase over three years. 2003/2004 Facility Location of Death: Calgary and South Rural Areas Trauma Centre Deaths: Foothills Medical Centre: 98 Alberta Children s Hospital: 7 Total:

110 District Centre Deaths by Location (2003/2004) # of patients 5 5 Lethbridge Medicine Hat Red Deer RGH PLC District Centres: 31 Rural Acute Care Sites*: 14 * Locations may be designated as acute care/auxillary and ambulatory care Nursing Home/Auxiliary sites: 6 Other**: 7 **Includes palliative care facilities, corrections facilities and free standing psychiatric facilities 2003/2004 Overall Total: /2005 Facility Location of Death: Calgary and South Rural Areas Trauma Centre Deaths: Foothills Medical Centre: 96 Alberta Children s Hospital: 10 Total: 106 District Centre Deaths by Location (2004/2005) 14 # of patients Lethbridge Medicine Hat Red Deer RGH PLC District Centres: 47 Rural Acute Care Sites*: 28 * Locations may be designated as acute care/auxillary and ambulatory care Nursing Home/Auxiliary sites: 3 Other**: 6 **Includes palliative care facilities, corrections facilities and psychiatric facilities Overall 2004/2005 Total =

111 2005/2006 Facility Location of Death: Calgary and South Rural Areas Trauma Centre Deaths: Foothills Medical Centre: 126 Alberta Children s Hospital: 7 Total: 133 District Centre Deaths by Location (2005/2006) # of patients Lethbridge M edicine Hat Red Deer RGH PLC District Centres: 49 Rural Acute Care Sites*: 19 * Locations may be designated as acute care/auxillary and ambulatory care Nursing Home/Auxiliary sites: 6 Other**: 1 **Includes palliative care facilities, corrections facilities and psychiatric facilities Overall 2005/2006 Total = 208 Total Facility Deaths/Year # of patients / /

112 Appendix A: Facility/Hospital Trauma Deaths, 2003/ /06 Facility Name 2003/ / /06 Agape Manor Hospice Alberta Children's Hospital Alberta Hospital Ponoka Banff Mineral Springs Hospital Bassano Health Centre Bethany Care - Calgary Bethany Care - Harvest Hills Bowden Institution Brooks Health Centre Canmore General Hospital Cardston Hospital Carewest Sarcee Carewest Sarcee Hospice Claresholm General Hospital Coaldale Health Care Centre Consort Municipal Hospital Crowsnest Pass Hospital Didsbury Health Centre Drumheller District Health Services Drumheller Institution Extendicare - Cedars Villa Father Lacombe Foothills Medical Centre Fort Macleod Hospital Hanna District Health Services High River Hospital & Nursing Home Innisfail Health Centre Lacombe Hospital and Care Centre Lethbridge Regional Hospital Magrath Hospital Mayfair Care Centre Medicine Hat Regional Hospital Milk River Hospital Oilfields General Hospital Olds Hospital and Care Centre Peter Lougheed Centre Pincher Creek Hospital Ponoka Hospital and Care Centre Red Deer Nursing Home Red Deer Regional Hospital Red Deer Regional Hospital Centre Rimbey Hospital and Care Centre Rocky Mtn House Hospital & Care Centre Rockyview General Hospital Rosedale Hospice Smith Funeral Home Stettler Health Centre Strathmore District Health Services Sundre Hospital and Care Centre

113 Facility Name 2003/ / /06 Taber Hospital Three Hills District Health Services Tom Baker Cancer Centre Valley General Hosp Vulcan Community Health Centre Total

114 Regional Department of Emergency Medicine Report Submitted by: Judy Pedersen Service Planning Coordinator Regional Emergency Services Calgary Health Region

115 Overview The Calgary Health Region s urban Emergency Departments play an integral role in providing emergency care to residents of Region 3, Southern Alberta, Southeastern British Columbia, Southwestern Saskatchewan and out of province visitors. A population of nearly 1.5 million is served. The Emergency Departments (EDs) provide a unique service to the community and to the hospitals, caring for a large number of patients with diverse and complex health concerns. A full scope of service is provided and ranges from resuscitation to the treatment of patients with nonurgent conditions. The EDs play a key role in partnering with Trauma Services to effectively manage the population of trauma patients. For many trauma patients, the Emergency Department is their first major point of entry to the health care continuum. The Regional Department of Emergency Medicine (RDEM) Services is responsible for the operations of the three urban adult Emergency Departments within the Calgary Health Region including the Foothills Medical Centre (FMC), Peter Lougheed Centre (PLC) and the Rockyview General Hospital (RGH). There are over 200,000 emergency visits each year among these three sites. While the Emergency Department at the Alberta Children s Hospital (ACH) is administered under the Child & Women s Health Portfolio, there is a close working relationship with (RDEM). ACH receives approximately 45,000 patient visits each year. The FMC and ACH are the designated adult and pediatric tertiary trauma centres for Southern Alberta respectively, but the PLC and RGH also receive and treat trauma patients as well. The EDs provide 24-hour access to health care for individuals of all ages who have unscheduled health care needs. In order to manage this diverse patient population, all Calgary Health Region EDs use the nationally recognized, standardized triage-scoring system known as the Canadian Triage Acuity Scale (CTAS). Experienced and highly trained ED Nurses assign each patient a priority level based on how they present upon arrival to the ED. The CTAS ratings include 1 (resuscitation), 2 (emergent), 3 (urgent), 4 (semi-urgent) and 5 (non-urgent). It is important to note that the CTAS score is reflective of how the patient presents upon arrival and that their condition may improve or worsen over the course of their ED visit. The following information was excerpted from Implementation Guidelines for The Canadian Emergency Department Triage and Acuity Scale (CTAS) which is endorsed by the Canadian Association of Emergency Physicians (CAEP), the National Emergency Nurses Affiliation of Canada (NENA), and L association des medcins d urgence du Quebec (AMQU). Please note that we have only presented CTAS Level classification information as it applies to trauma patients. There is a wide range of other types of patients that fall within each CTAS category as well. Trauma patients presenting to the ED are classified as follows: CTAS Level 1 Resuscitation Major trauma: severe injury of any single body system or multiple system injury, Head injury with Glasgow Coma Scale < 10, severe burns, chest/abdominal injury with any or all of: altered mental state, hypotension, tachycardia, severe pain, respiratory signs or symptoms CTAS Level 2 Emergent Head injury: This problem appears in several triage levels. The more severe or high-risk patients require a rapid MD assessment, to determine the requirements for airway protection/ct scanning or neurosurgical intervention. These patients usually have an altered mental state (Glasgow Coma Scale 13). Severe headache, loss of consciousness, confusion, neck symptoms and nausea or vomiting can be expected. Details regarding the time of impact, mechanism of injury onset and severity of symptoms and changes over time are very important. Severe trauma: These patients may have high-risk mechanisms and severe single system symptoms or multiple system involvement with less severe signs and symptoms in each. Generally the physical assessment of these patients should reveal normal or nearly normal

116 vital signs (Abnormal VS are CTAS level 1). These patients may have moderate to severe pain and normal mental status (or meet the criteria outlined for level II head injuries). CTAS Level 3 Urgent Head injury: these patients may have had a high-risk mechanism. They should be alert (GCS 15) moderate pain (< 8/10) and nausea or vomiting. Should be changed to level 2 if deteriorating or just appears unwell. Moderate trauma: Patients with fractures or dislocations or sprains with severe pain (8-10/10). Nursing intervention with splinting/analgesics making it reasonable to have some delay in time to physician assessment/intervention. Dislocations should be reduced within one hour, so physician assessment should occur in 30 minutes. Patients are stable (normal or near normal vital signs). CTAS Level 4 Semi-Urgent Head Injury: Minor head injury, alert (GCS 15), no vomiting or neck symptoms and normal vital signs. May require brief period of observation, depending on time of injury in relation to ED visit. If time interval from accident > 4-6 hours and has remained free of symptoms, a neuro check and head routine sheet may be all that is necessary. The age of the patient and characteristics of the care provider/support at home may also influence the disposition decision or observation period. Minor trauma: minor fractures, sprains, contusions, abrasions, and lacerations, requiring investigation or intervention. Normal vital signs, moderate pain (4-7/10). CTAS Level 5 Non-Urgent Minor trauma: contusions, abrasions, minor lacerations (not requiring closure by any means), overuse syndromes (tendonitis), and sprains. Nursing interventions, splinting, cleansing, immunization status, minor analgesics are all expectations of patients in this category. Trauma Patient Quality Improvement Practices A series of treatment protocols, standards and guidelines have been developed for managing trauma patients in the ED in close collaboration with the Regional Trauma Services team. Quality Improvement processes are established to monitor and evaluate compliance. The RDEM participates actively on the Calgary Health Region Trauma Committees, which facilitate open communication, collaboration and problem solving. Protocols, standards and policies related to managing trauma patients are reviewed annually and on an ad hoc basis based on current research evidence. The following standards, guidelines, and protocols are monitored by Trauma Services: Trauma Team activation based on activation criteria Trauma Team Leader (TTL) response time </= 20 minutes from patient arrival. Compliance with Spinal Clearance Protocol based on the Canadian C-spine study Documentation of vital signs qhour for all trauma patients in the ED Documentation of sequential neurological vital signs as appropriate ED length of stay </= 4 hours Admission of major trauma patients to a non-surgeon or non-intensivist Use of mechanical airway in ED for patients with a first recorded GCS </= 8 Joint dislocations reduced less than 1 hour of arrival Time to CT of the head for patients with a GCS < 13 (standard is < 4 hours) Time to craniotomy for patients with epidural or subdural brain hematoma Time to laparotomy for patients with suspected intra-abdominal injury Note: Regional Trauma Services collects data in the Alberta Trauma Registry on all major trauma patients with an ISS >/= 12 who are admitted to hospital or die in the Emergency Department. ISS is an anatomical scoring tool indicating severity of injury

117 In addition to the above, Emergency Nurse Clinicians have been working closely with Trauma Services to understand the importance of thorough documentation and the subsequent impact on Trauma Registry data. It is also Emergency Department practice for any unusual matters to be brought to the attention of the Trauma Clinical Nurse Specialist. The Emergency Department actively participates in a wide range of Quality Improvement projects, most of which will positively impact the care of all emergency patients, including those who are trauma victims. Some examples include: Enhanced triage staffing at all sites and implementation of triage guidelines regarding reassessment of waiting room patients according to CTAS level. Renovations/upgrades to triage areas at FMC and PLC were also completed to better facilitate triage activities. Credentialing of ED physicians under the Canadian Association for Emergency Physicians (CAEP) to perform FAST (Focused Assessment with Sonography for Trauma) ultrasound in the department for conditions including pericardial tamponade, intrauterine pregnancy, abdominal aortic aneurysm, abdominal trauma and cardiac standstill. FAST is an extension of the clinical assessment and most helpful in trauma patients in shock. A FAST protocol was developed, in conjunction with Trauma Services and Diagnostic Imaging for trauma patients. The credentialed ED physicians and trauma surgeons perform FAST as part of the trauma patient assessment. Developing an alphanumeric, one-call paging system to improve timely response from, and communication with, the trauma team. Participating in a spinal management project that examined, and aimed, to improve and standardize practices, processes and safe care for patients in the Emergency Department and in the Diagnostic Imaging Department. Participating in a review of the equipment/protocol for treatment of hypothermia patients. Reviewing trauma patient cases that were identified by Trauma Registry as meeting the Trauma Team Activation criteria but the team was not activated at the discretion of the emergency physician. Some cases were flagged and reviewed at the FMC Trauma Clinical Safety meetings to identify issues

118 Conclusion Emergency Department Annual Registered Visits - Urban Sites 280, , , , , , , , , , , ,000 ED Visits 220, , , ,000 97/98 98/99 99/00 00/01 01/02 02/03 03/04 04/05 05/06 ED Visits Annually ED Trends Since 2000/01 by Site /01 01/02 02/03 03/04 04/05 05/06 ACH FMC PLC RGH The volume of Emergency Department patient visits increased by approximately 2.5% in 2005/2006 when compared to 2004/05. This resulted in an additional 7,025 visits to the Emergency Departments at the urban sites. The FMC site experienced an increase in activity of 6% since in 2005/2006; PLC experienced an increase of 3%. RGH experienced a decrease in 2005/2006, which may be an indication of the impact of the opening of the Urgent Care Centre at South Calgary Health Centre. The profile of the patients presenting to the Emergency Departments also changed over this time period. The percentage of patients over the age of 40 increased with the largest increase in patients yrs of age, while the age group showing the largest decrease was less than 10 years of age group. The older group of patients tended to be more complex and required more extensive investigative work as they often had a higher presenting acuity. As a result of these shifts an increased number of patients presenting to ED showed a higher level of acuity and were older. The acuity of all patients presenting also shifted with the percentage of CTAS 2 increasing from 14% in 2002/2003 to 23% in 2005/2006 of all patients presenting. The number of patients

119 requiring admission to hospital continued to increase which was another indication of the increasing acuity of those presenting to the ED. CTAS 1 and 3 remained stable while CTAS 4 patients decreased from 26% in 2002/2003 to 21% in 2005/2006. The CTAS 5 patients decreased from 5% to 3%. The combination of the high volumes, increased acuity and an aging population contributed to longer wait times and overall length of stay (LOS) in the ED for all types of patients. 35% Proportions of ED Visits by Age Group at Adult Sites 30% Percentage (%) 25% 20% 15% 10% 5% 0% and over 2003/ / / Age Group (Years) The average length of stay (ALOS) in ED for all patients requiring admission to hospital increased at all sites reflecting in part the lack of inpatient capacity within the acute care sites. The ALOS for patients discharged from Emergency remained stable. Length of Stay in the Emergency Department for Admitted and Discharged Patients (Average) Annually Hours / / / /06 FMC Admit RGH Admit PLC Admit All Discharged Fiscal Year The standard for length of stay for major trauma patients in ED is 4 hours. For 2005/2006, the ED LOS for major trauma patients in the FMC ED was </= 4 hours 36.7% of the time (334 patients); > 4 hours 63.3% of the time (577 patients). The median LOS was 5.3 hours. Patients were excluded if they were direct admits or times were not recorded. ACH ED LOS was </= 4 hours 62.1 % of the time (44 patients);> 4 hours 37.9% of the time (26 patients). The median LOS was 2.95 hours

120 P.A.R.T.Y. PROGRAM (Prevent Alcohol Related Trauma in Youth) Submitted by: Lynda Vowell, RN BN P.A.R.T.Y. Coordinator Emergency Services Calgary Health Region