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ALBERTA CHILDREN’S HOSPITAL

PEDIATRIC TRAUMA PROGRAM

ANNUAL REPORT

2017

ACH Trauma Program Staff

Dr. Jonathan Guilfoyle ............................................................. Medical Director

Dr. Natalie Yanchar ...................................................... In-Patient Surgical Lead

Jennifer Tweed ....................................................... Trauma Program Manager

Sherry MacGillivray ........................................................... Trauma Coordinator

Lisette Lockyer ........................................................ Trauma Nurse Practitioner

Linda-Mae Grey ............................................................................... Data Analyst

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TABLE OF CONTENTS

1. Introduction .................................................................................................... 3

2. Clinical Care .................................................................................................. 7

3. Education .................................................................................................... 10

4. Research ..................................................................................................... 13

5. Quality Assurance ....................................................................................... 16

6. Future Planning .......................................................................................... 17

APPENDICES

Appendix A Trauma Quality Indicators .......................................................... 18 Appendix B Major Trauma Statistics.............................................................. 35

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1. Introduction The ACH Trauma Program has enjoyed another productive and successful year as we continue to strive for excellence across the entire spectrum of trauma care. In the coming year we will continue to prepare for our upcoming re-accreditation through Accreditation Canada. We believe that our Trauma Program’s emphasis on prevention, education, and coordinated, collaborative, evidence-based, multi-disciplinary care are fundamental to our success and we welcome this opportunity to ensure that we continue to deliver the highest level of care to the children of Southern Alberta. The first step in trauma care is injury prevention. Our program is a vocal advocate for injury prevention and we are fortunate to have partners at both the provincial and national level. Through both our own database and through the Canadian Hospital Injury Reporting Prevention Program (CHIRPP), we are able to monitor injury trends and target areas of intervention. One such intervention stemmed from the recognition of the frequency of falls from second-storey windows, particularly in the summer months. The ACH Trauma Program has partnered with the City of Calgary to bring forward an amendment to the National Building Code to restrict the opening of windows in an effort to prevent such injuries. Other initiatives include educational efforts to highlight the risk of ATV use in children as well as petitioning the provincial government to legislate stricter regulations for their use in minors. We are also collaborating on a national effort to collect further data on the nature of ATV injuries in children. Education has always been one of the great strengths of this Trauma Program, which we continue to build upon. The ACH Trauma Program continues to provide educational leadership for both ACH clinical staff, as well as outreach education to rural and regional providers. On-going education provided by the Pediatric Trauma Program includes: mock/just-in-time trauma codes for the ED; monthly Pediatric Trauma Rounds; twice yearly Trauma Nursing Core Courses (TNCC); and outreach education to referral centers by partnering with the KidSIM™ program at ACH. We run regular mock trauma codes that involve the entire trauma team, beginning in the trauma bay and continuing to the OR. In June 2017 ACH participated in a city wide mock Code Orange activation that simulated an ‘active shooter’ scenario with mass casualties. This highlighted the stress such an event would place on our Institution’s resources and we gained valuable insights from participating. In March of 2017 the ACH Trauma Program was again involved in the Pediatric Emergencies Alberta Children’s Hospital (PEACH) conference, offering lectures and simulations focused on trauma care for rural providers. In May of 2017 ACH hosted one of the first Trauma Resuscitation in Kids (TRIK) instructor courses which was a great success and graduated over 20 certified TRIK instructors. Due to the hard work of the KidSono team, point of care ultrasound has now become standard practice in our trauma bay. The majority of our TTLs are now certified in the Focused Assessment with

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Sonography in Trauma (FAST) and with the implementation of the KidSono online learning modules many are learning advanced ultrasound skills as well. Another ongoing educational initiative is the monthly simulation program specifically for Emergency Physician Attendings. This program has been developed to help our physicians maintain competency in critical resuscitation skills that they may only infrequently use in their day-to-day clinical practice. The simulations occur in our trauma bay and include a full complement of nurses and an RRT to enhance the realism of the scenario. This has been coupled with a new ACH Pediatric Airway Course that most of the physician group has completed. The Brain Injury and Rehabilitation Program continues to provide services for patients who have suffered traumatic brain injuries. This program includes in-patient comprehensive rehabilitation services, as well as outpatient services in coordination with Gordon Townsend School. The ACH Trauma Program would like to extend a heartfelt thank you to our amazing Emergency Medical Services team. They provide exceptional care, with limited resources, in the most austere environments and we are greatly appreciative of the work they do and the lives they save. We are in regular communication with EMS and they frequently attend our various meetings, so that together we can optimize the pre-hospital care of pediatric patients. Our rural partners do an excellent job of providing high-level care despite the broad geography of Southern Alberta and the disparate allocation of resources that can pose significant logistical challenges. The Trauma Program works closely with both the ACH Transport Team and Shock Trauma Air Rescue Society (STARS) to ensure the timely transport of these critically injured patients to ACH where they can receive definitive care. We are also in close contact with our rural partners, providing both feedback and educational outreach. We would like to specifically recognize the Lethbridge Hospital who did an outstanding job of managing a toddler with a penetrating cardiac injury that required an emergency thoracotomy. Due to the Lethbridge team’s expertise and decisive action, this very lucky boy has made a full recovery. This was by far the biggest save of the year and the entire team deserves kudos. Upon arrival to ACH, trauma patients are met by a world class, multi-disciplinary trauma team. The Trauma Program has developed and refined a trauma activation system that ensures that this team is assembled and ready promptly. The Trauma Team Leader (TTL) is a designated Emergency Physician currently on shift whose first priority is to manage resuscitations in the Trauma Bay. The Trauma Surgery Team responds to all trauma activations and co-manages the patient alongside the TTL, then assuming responsibility for the in-patient management of these children. The Pediatric Intensive Care Team also responds to all activations providing their expertise in the management of critically ill patients and providing on-going care for those patients requiring intensive care.

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In addition to a Trauma Team Activation, we also have an OR Activation system which immediately mobilizes the OR Team and the on-call anesthesiologist for patients with airway emergencies or those that require an immediate operation. A child with multi-system injuries may also require the services of multiple other surgical subspecialties. We enjoy a great working relationship with our radiology department who also respond to all trauma activations, providing timely access to diagnostic imaging around the clock. The radiology department has committed to providing attending reads of all trauma activations within the hour in order to ensure accuracy and minimize discrepancies between preliminary and final reports. They have also committed to providing interventional radiology support 24/7. We are most fortunate to have such an incredible group of trauma nurses in our emergency department who are invaluable to our team. Nurses have the opportunity to maintain their skill set through the Trauma Nursing Core Course (TNCC) that is provided bi-annually, as well as a wide range of simulation programs with which our nurses are integrally involved. We also have an exceptional respiratory therapy team that respond to all activations. As one can well imagine, the coordination of all of these disciplines for a critically injured child with competing medical issues is essential to provide the highest level of care. The ACH Trauma Program continually endeavors to bridge gaps and to optimize seamless care for these patients. We have broad subspecialty representation at our monthly Trauma Committee meetings which provides a forum to share concerns and make recommendations to further optimize our system. Our mock codes serve to further foster the close working relationship and teamwork among the various specialties caring for these patients. The In-patient Trauma Program provides integrated care for patients and families, from time of first assessment through hospital discharge. They are supported by multiple surgical subspecialties, including but not limited to pediatric general surgery, orthopedic surgery, neurosurgery, plastic surgery, and urology. In-patient pediatrics and rehabilitation medicine are instrumental in long-term return to function and getting kids home as quickly as possible. Obviously the care of children with multi-system injuries is complex but is supported by a dedicated group of healthcare professionals including nursing, physical therapy, and social work. The Pediatric Trauma Program continues to collaborate on many provincial and national projects through the Provincial Trauma Committee of Alberta, the Interdisciplinary Trauma Network of Canada and the Trauma Association of Canada (TAC). We are very proud of Dr. Natalie Yanchar our Surgical Lead who is our new TAC Board president and our Trauma Coordinator Ms. Sherry MacGillivray who was elected to the TAC Board of Directors. Calgary will be hosting the next TAC meeting in February of 2019, which we hope many of you will attend.

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Finally, we wish to express our appreciation for all of the staff at the Alberta Children’s Hospital, who continue to support our goals in caring for critically injured children and youth. Dr. Jonathan Guilfoyle would like to personally thank all the members of the Trauma Program for their hard work and commitment to ongoing excellence in Pediatric Trauma Care at the Alberta Children’s Hospital. Above all, he would like to thank Ms. Sherry MacGillivray for her tireless dedication and commitment to our Pediatric Trauma Program. Trauma Committee Members 2017: Dr. Jonathan Guilfoyle (chair) Dr. Natalie Yanchar (surgery lead) Dr. Andrea Boone (emergency lead) Dr. Eli Gilad (PICU) Dr. Jeremy Luntley / Dr. Jamin Mulvey (anesthesiology) Dr. Cathy Chrusch (diagnostic imagining) Dr. Clare Gallagher (neurosurgery) Dr. Fabio Ferri de Barros (orthopedics) Wendy Bissett (PICU) Lisette Lockyer (trauma NP) Jessica Graham / Laura Slipp (OR) Jennifer Tweed / Suzanne Wickware (emergency) Colleen Belanger (in-patient trauma unit) Kathy Lyons (social work) Nora Ansah (injury prevention) Sherry MacGillivray (trauma coordinator) NOTE: The patients included in this report are those with an Injury Severity Score (ISS) > 12 and who are admitted to the hospital or die in the emergency department at the Alberta Children’s Hospital (ACH). Patients who die at the scene of their traumatic event are not represented in this report. ISS is an anatomical scoring tool that provides an overall score for patients with single or multiple system injuries. The ISS captured in the Alberta Trauma Registry ranges between 12 and 75. The assumption is the higher the ISS score, the more serious the injury suffered.

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2. Clinical Care Identifying ways to improve the clinical care of the trauma patient at the ACH is a major focus of the Pediatric Trauma Program.

i) Trauma In-patient Unit • Unit 4 continues to be the ACH trauma unit. This has allowed the care of

all traumatic injuries to be consolidated within one group of care providers who continue to show dedication and excellence in the care they provide.

ii) Pediatric In-patient Trauma Service

• A dedicated in-patient trauma service, to provide and direct the primary clinical care of multiply injured trauma patients, continues to be well led by the Division of Pediatric General Surgery. They provide attending physician coverage for this service 24/7.

iii) Trauma Tertiary Survey • The Pediatric Trauma Tertiary Survey is to be completed by the in-patient

trauma service on all major trauma patients at 24 hours after admission. This helps to identify missed injuries or issues early in the patients stay.

iv) Pediatric Trauma Nurse Practitioner

• This position supports the in-patient trauma service, as well as plays a significant role on the Brain Injury Team. The Trauma Nurse Practitioner also runs an outpatient follow up Trauma Clinic.

v) Trauma Team Activation Guidelines (Code 77) • A Code 77 is activated by a nurse in the Emergency Department for major

trauma patients using specific guidelines that include physiological, anatomical and mechanism of injury. These guidelines are continuously monitored for ‘over’ ‘under’ and ‘missed’ call and for any issues that arise. See Appendix A for 2017 details.

vi) OR Activation (Code 88)

• A Code 88 activation is called in order to mobilize the OR team for an anticipated emergent airway intervention and/or an anticipated need for an emergent OR. This is an automatic 24/7 response from Anesthesiology, Anesthesia RRT, OR Nursing team (3 RN’s), PACU nursing team (2 RN’s). The Pediatric Intensivist is also on the activation for those times they are in-house and can assist with a difficult airway. Activations are monitored and reviewed by the Trauma Committee.

vii) Trauma Team Leader Record • This is the documentation tool to be used by Trauma Team Leaders

(Emergency Physicians) looking after major trauma patients. It was created to help address gaps in documentation that were identified in Quality

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Management reviews. The tool is a combination of ‘check boxes’ and various prompts to ensure complete documentation of the assessment and management of trauma patients. A regular audit for % of completion for Code 77 patients is done and reported to the Trauma Committee. The 2017 completion rate was 96%.

viii) Provincial Nursing Trauma Resuscitation Record • As a directive from the Provincial Trauma Committee, in 2012 the Alberta

Trauma Coordinators developed the provincial nursing trauma record to be used in all emergency departments and urgent care centers in the province. This record was felt to be an important standardization of trauma care and management. It was revised in 2014 after feedback from the end users.

ix) Pediatric Massive Transfusion Protocol

• The Pediatric Massive Transfusion Protocol is available for use for all patients in ACH. These activations are evaluated in partnership with Transfusion Medicine. This protocol was revised in 2015. Additionally, there are 2 units of O negative pRBCs in the ED trauma room for immediate use.

x) Trauma ‘No Refusal’ Policy

• An ACH ‘No Refusal’ Policy for pediatric trauma patients was endorsed by the Pediatric Trauma Committee in 2010. It states that no pediatric trauma patient in the ACH catchment area will be refused or turned away from our facility. This is the case even when there are no PICU or in-patient beds available. Under those circumstances, patients will be accepted and stabilized in the ED at ACH while further disposition is arranged.

xi) Trauma Beading Program

• Thanks to continual generous grants from the Alberta Children’s Hospital Foundation, the Trauma Beading Program for major trauma patients remains on-going since 2008. The opportunity for admitted trauma patients to mark and remember their journey by earning beads for length of hospital stay, diagnostic tests and treatment modalities has been well received by both trauma patients and their families. This program, administered by the Pediatric Trauma Coordinator and operationalized by the ACH Child Life Specialists, has been a huge success. We would like to extend our gratitude to the ACH Child Life Specialists for making this important program a continued success.

xii) ACH Trauma Manual

• The ACH Trauma Manual is for new residents and staff physicians, as well as other disciplines working with trauma patients. The manual lives on the Trauma Services page on the internal website for AHS. It is revised as necessary by the Trauma Committee.

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xiii) Liaising with Regional, Provincial and National Groups • Provincial Trauma Committee - Members • Interdisciplinary Trauma Network of Canada - Members • Trauma Association of Canada - Members • National Emergency Nurses Association - Member • Canadian Hospitals Injury Prevention & Reporting Prevention Programs

(CHIRPP) - Members • Alberta Children’s Hospital Foundation liaison - for trauma families who

want to ‘give back’ by discussing their trauma experience in venues such as the annual Radiothon

• Shock Trauma Air Rescue Service (STARS) liaison for pediatric trauma patients

• Referral Access Advice Placement Information Destination (RAAPID) liaison for pediatric trauma patients

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3. Education

i) Trauma Rounds Rounds are held in the ACH Ampitheatre to accommodate telehealth to outside centres

• January 26, 2017 – Dr. Carlos Alvarez “ECMO in the Trauma Setting”

• February 23, 2017 – Dr. Jonathan Gilleland “Pediatric Blunt

Cerebrovascular Injury: when to investigate”

• March 23, 2017 – Dr. Jamin Mulvey “Controversies in the Modern Management of Pediatric Traumatic Cardiac Arrest”

• May 25, 2017 – Dr. Alaa Elmanzalawy “Pediatric Trauma Brain Injury:

Review of Current Imaging Practice”

• June 22, 2017 – Dr. Elaine Joughin & Dr. Nina Hardcastle “Traumatic Amputations”

• September 22, 2017 – Dr. Natalie Yanchar “Controversies and Conundrums in Management of Solid Organ Injuries in Children”

• October 26, 2017 – Dr. Sultan Jarrar “Management of Severe TBI and Indications for Hemicraniectomy”

• November 23, 2017 – Dr. Andrea Boone & Dr. Jaime Blackwood “Management of Accidental Hypothermia – an ACH Update”

ii) Trauma Nursing Core Course • The Trauma Nursing Core Course (TNCC) continues to be held at ACH

twice per year. This course is designed for nurses caring for patients in any part of the trauma spectrum and has international recognition. This course is taken by the ED nurses prior to working in the trauma room and has also been endorsed by management of the in-patient trauma unit.

iii) Mock/Just-in-Time Trauma Simulation

• These mocks provide physicians, fellows, residents, nurses, respiratory therapists, nursing aides and unit clerks with an opportunity to learn from simulated trauma cases. At least once per year, one of these mocks start in the ED with a full activation of both Code 77 & 88 moving up to the OR to involved the entire OR team as well as General Surgery and other surgical services (ie: Neurosurgery, ENT).

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iv) Outreach Education • The partnership between the ACH Trauma Program and KidSIM™, the

Pediatric Human Patient Simulation Program, continues to deliver education to both regional and rural partners. These are very popular multidisciplinary educational sessions that include pre-hospital as well as in hospital care givers.

The following centres were visited in 2017:

March Cardston, Fort McLeod April Didsbury May Medicine Hat, Strathmore June Cranbrook BC October Lethbridge, Claresholm, Canmore, High River November Red Deer, Okotoks December Brooks, Bassano

v) Emergency Department Trauma Simulation Sessions

• Trauma simulation sessions are held for ED nurses as part of their annual education in conjunction with residents and fellows rotating through Pediatric Emergency Medicine. Human Patient Simulators were used to replicate the assessment and management of trauma patients in real time in an interprofessional environment. In 2015 the ED staff attending physicians joined this program for in-situ scenarios in the ED trauma room with the entire ED trauma team.

vi) Nursing Trauma Simulation Sessions

• Trauma education is included in General Nursing Orientation for all new PICU, ED and Unit 4 (trauma unit) nurses at the ACH as well as the rotating nursing support team. Adult ED nurses in the Calgary area also have one day with the pediatric educators, where trauma education and simulation are introduced.

vii) Trauma Association of Canada Annual Conference (Vancouver, BC – February 2017) • Presidential Address “TAC to the Future” – Dr. Natalie Yanchar • “The ACH Trauma Checklist”, “High Stakes & Low Volumes; Maintaining

Quality in Pediatric Trauma Resuscitation” – Sherry MacGillivray • “Unplanned Emergency Department/Urgent Care Centre Visit or Hospital

Readmission within 30 days of Discharge from a Pediatric Trauma Center” Poster presentation – Linda-Mae Grey & Sherry MacGillivray

viii) Pediatric Emergencies Alberta Children’s Hospital (PEACH) Annual Conference (Calgary, AB – March 2017) • “Tales from the Trauma Archives” – Dr. Jonathan Guilfoyle

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ix) Trauma Resuscitation in Kids (TRIK) Instructor Course (Calgary, AB – May 2017)

x) University of Calgary, Medical Education

• Medical Student Course VI Lecture: Introduction to Pediatric Trauma – Dr. J. Guilfoyle

• Family Medicine Resident Academic Half-Day: Approach to Pediatric Trauma – Dr. J. Guilfoyle

• Pediatric Resident Academic Half-Day: Multi-trauma in the ER– Dr. J. Guilfoyle

• Emergency Medicine Resident Academic Half-Day: Pediatric Trauma: Pitfalls and Pearls – Dr. J. Guilfoyle

• PEM Fellow Academic Day: An Evidence Based Review of Severe TBI – Dr. J. Guilfoyle

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4. Research

The following research projects were in progress or completed during 2017:

PUBLICATIONS:

1) MacGillivray S, Grey LM, Guilfoyle J, Lopushinsky S “Unplanned Emergency Department/Urgent Care Centre Visit or Hospital Readmission within 30 days of discharge from a Pediatric Trauma Centre” J of Trauma & Acute Care Surgery. Abstract.

2) Lopushinsky S, Lockyer L, Daodu O, Alvarez-Allende C, Brindle M, Weber B “Outcomes of an Accelerated Care Pathway for Pediatric Blunt Solid Organ Injuries in a Public Healthcare System” J Pediatric Surgery. 2017 May;52(5):826-831

3) Thompson B, Thull-Freedman J, Page S, Ferri de Barros F. “Creating a

Multi-Disciplinary Shared Decision-Making Pathway for Pediatric Low-Risk Fractures. Calgary Zone Quality Council. 2017

4) Audet O, Hagel BE, Nettel-Aguirre A, Mitra TP, Emery CA, Macpherson A,

Lavoie MD, Goulet C. What are the risk factors for injuries and injury prevention strategies for skiers and snowboarders in terrain parks and half-pipes? A systematic review. Accepted: British Journal of Sports Medicine.

5) Richmond SA, Donaldson A, Macpherson A, Bridel W, Van den Berg C, Finch C,

Hagel BE, Emery CA. Facilitators and barriers to the implementation of iSPRINT: a sport injury prevention program in junior high schools. Clinical Journal of Sport Medicine. Clinical Journal of Sport Medicine: March 26, 2018 - doi: 10.1097/JSM.0000000000000579

6) Sran R, Djerboua M, Romanow NTR, Russell K, White K, Goulet C, Emery CA,

Hagel BE. Ski and snowboard school programs: Incidence and risk factors for injury. Scandinavian Journal of Medicine and Science in Sport 2018;1-9: doi: 10.1111/sms.13040.

7) Black AM, Hagel BE, Palacios-Derflingher L, Schneider KJ, Emery CA. The Risk

of Injury Associated with Body Checking among Pee Wee Ice Hockey Players: An evaluation of Hockey Canada’s national body checking policy change. British Journal of Sports Medicine 2017; doi: 10.1136/bjsports-2016-097392. [Epub ahead of print]

8) Moore L, Boukar KM, Tardif PA, Stelfox HT, Champion H, Cameron P, Gabbe B,

Yanchar N, Kortbeek J, Lauzier F, Légaré F, Archambault P, Turgeon AF. Low-value clinical practices in injury care: a scoping review protocol. BMJ Open 2017;7(7):e016024

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9) Moore L, Champion H, O'Reilly G, Leppaniemi A, Cameron P, Palmer C, Abu-Zidan FM, Gabbe B, Gaarder C, Yanchar N, Stelfox HT, Coimbra R, Kortbeek J, Noonan V, Gunning A, Leenan L, Gordon M, Khajanchi M, Shemilt M, Porgo V, Turgeon AF; Impact of trauma system structure on injury outcomes: A systematic review protocol. Syst Rev 2017;6(1):12.

10) Gill PJ, McLaughlin T, Rosenfield D, Hepburn CM, Yanchar NL, Beno S. All-terrain vehicle serious injuries and death in children and youth: a national survey of Canadian paediatricians. Paed and Child Health 2017, in press.

11) Moore L, Evans D, Yanchar NL, Thakore J, Stelfox HT, Hameed SM, Simons R,

Kortbeek J, Clement J, Lauzier F, Turgeon AF. Canadian benchmarks for acute injury care. CMAJ 2017 60(6):380-7

12) Tansley G, Schuurman N, Erdogan M, Bowes M, Green R, Asbridge M,

Yanchar NL. Development of a model to quantify the spatial accessibility of a Canadian trauma system. CJEM 2017;19(4):285-92

13) Jessula S, Murphy N, Yanchar NL. Injury severity in pediatric all-terrain vehicle-

related trauma in Nova Scotia. J Pediatr Surg. 2017;52(5):822-5. (IF: 1.7)

14) Moore L, Evans D, Hameed SM, Yanchar NL, Stelfox HT, Simons R, Kortbeek J, Bourgeois G, Clément J, Lauzier F, Nathens A, Turgeon AF. Mortality in Canadian Trauma Systems: A Multicenter Cohort Study. Ann Surg. 2017 Jan;265(1):212-217. (IF: 8.3)

15) Walsh J, Schmit P, Yanchar N. Should grade of solid organ injury determine

need for hospitalization in children? J Trauma Acute Care Surg. 2017 Jan;82(1):109-113. (IF: 2.8)

16) Moore L, Stelfox HT, Evans D, Hameed SM, Yanchar NL, Simons R, Kortbeek

J, Bourgeois G, Clément J, Turgeon AF, Lauzier F. Trends in Injury Outcomes Across Canadian Trauma Systems. JAMA Surg. 2017 Feb 1;152(2):168-174. (IF:5.7)

17) Pike I, Khalil M, Yanchar NL, Tamim H, Nathens AB, Macpherson AK.

Establishing an injury indicator for severe paediatric injury. Inj Prev. 2017;23(2):118-23.

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IN PROGRESS:

1) Charyk-Stewart T, MacGillivray S, Widas L, Falconer C, McDowall D, Brennan

M, Lake J, Bailey K. “National Pediatric Trauma Care Quality Indicators Project”

2) Pandya A, MacGillivray S, McKee J, Guilfoyle J, Joffe A, Thompson GC. “Traumatic Brain Injury and Sepsis in Children Admitted to Hospital Following Major Trauma”

3) Ferri-de-Barros F, Brauer C, Stelfox, T. “Quality indicators in the Management

of Supracondylar Humeral Fractures in Children: A family centered analysis of care”

4) Lee P, Lam R, MacGillivray S, Cheng A, Guilfoyle, J, Mikrogianakis A,

Grant V. “The Use of a Pediatric Trauma Checklist to Improve Clinical Performance in a Simulated Trauma Resuscitation: a randomized trial”

5) Bal C, Bryan P, Wishart I, MacGillivray S, Grey LM. “Determining the Utility of

Laboratory Tests Ordered in the Trauma Lab Workup for Emergency Patients that Meet Code 77 or Trauma Team Activation Criteria at the Alberta Children’s Hospital”

6) Joughin E. “Evaluation of Pain Management for Pediatric Orthopedic Patients

After Discharge from Hospital”

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5. Quality Assurance As part of the Pediatric Trauma Program quality improvement process, several performance indicators throughout the continuum of care are monitored on a regular basis as a measure of performance. Some of the indicators stem from audit filters set out by the American College of Surgeons’ Committee on Trauma and Trauma Registry performance measures published by the South Western Sydney Region Trauma Department, Liverpool, Australia. Other indicators were developed at the ACH as site specific performance indicators. All cases flagged by a performance indicator or audit filter are reviewed by the ACH Pediatric Trauma Quality Management Committee to determine appropriateness of care and follow-up to care providers and trauma systems. The list of performance indicators is listed below and are summarized in Appendix A. Pre-ACH care:

1. Presence of pre-hospital documentation from any phase of patient transport. 2. GCS < 8 at scene with mechanical airway intervention. 3. Length of stay at rural hospital > 2 hours. 4. Injury time to Trauma Center (TC) < 4 hours (for transferred patients). 5. Utilization of ACH Transport team for transfer.

Resuscitative care: 6. Trauma Team Activation. 7. Direct admission (bypassed the Emergency Department (ED)). 8. GCS <8 at the TC with mechanical airway intervention. 9. Presence of ED nursing documentation every 30 minutes. 10. Presence of sequential neurological documentation in the ED for suspected head/spinal cord

injuries. 11. Hypothermic in the ED (< 35.0˚C). 12. GCS < 12 in the TC with a CT head performed within 4 hours from trauma center arrival (TCA). 13. Patient stay in the ED less than 4 hours.

Definitive care: 14. Admission to a surgeon or intensivist. 15. Craniotomy within 4 hours after TCA with unstable epidural/subdural hematoma. 16. Missed cervical spine injury after 48 hours from TCA without maintaining spinal precautions. 17. Any laparotomy procedure performed. 18. Femur fracture to the OR within 24 hours from TCA. 19. Open long bone fracture to the OR within 6-12 hours from TCA (depending on the severity of #). 20. Unplanned return to the OR within 48 hours of initial procedure. 21. Missed injuries identified after 48 hours from TCA. 22. Reduction of joint dislocation/fracture dislocation after 1 hour from TCA. 23. Revascularization of an ischemic limb within 6 hours from the time of injury. 24. ORIF of facial fractures within 7 days after injury. 25. Operative repair of spinal fractures within 7 days after injury. 26. Pelvic ring fracture/acetabular fracture (with hemodynamic instability) provisional stabilization > 6

hours from TCA. 27. Definitive treatment of displaced acetabular fracture > 7 days from TCA. 28. Unplanned PICU admission or re-admission.

Outcome: 29. Death during the first 24 hours from TCA. 30. Did the patient die in ACH?

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6. Future Planning The 2018 year will focus on the following activities: • Preparation for upcoming accreditation • Continuing to optimize the functioning of our Trauma Team Leader Program • Continuing to focus on quality Pediatric Trauma Education • Continuing advocacy of Injury Prevention initiatives • Continuing leadership on a regional, provincial and national level • Continuing an active pediatric trauma research program • Continuing excellence in quality assurance leadership • Continuing to improve communication with all of the services impacted in trauma

delivery through the Trauma Committee • Establishing and growing connections with other Canadian Pediatric Trauma

Programs to work collaboratively on research, quality assurance projects and improving standards of care for pediatric trauma patients

• Continuation of an Attending Physician focused, CME accredited, simulation based, professional development program

• Continuation of running the Royal College Accredited, Trauma Resuscitation in Kids (TRIK) course

ACH Trauma Quality Indicators (ISS >12) 2017

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Appendix A Alberta Children’s Hospital Trauma Quality Indicators for 2017 Pre-ACH Care: 1. Presence of pre-hospital documentation from any phase of patient transport.

Are all pre-hospital ambulance reports from all phases of patient transport present on the medical record? Exclusions: Inappropriate where patients arrived by private vehicle, walk-ins, and unknown how patient arrived at hospital. Unknown: missing PCR. Inclusions: n = all patients with pre-hospital care provider(s).

99

93

98 97100

2 37

1

2013/2014 2014 2015 2016 2017

%Yes %No

Indicator Yes No

2017 n = 43 43 0 2016 n = 33 32 1 2015 n = 63 62 1 2014 n = 76 71 5 2013/2014 n = 80 79 1

Cooperation with Alberta Health Services EMS allows on-line record access, however obtaining out of province pre-hospital documentation is still challenging at times. 2. Glasgow Coma Scale (GCS) < 8 at scene with mechanical airway intervention.

Did the patient with a first recorded scene GCS < 8 receive mechanical airway intervention at the scene? Mechanical airway includes: oral intubation, nasal intubation, tracheostomy, and cricothyroidotomy. It does not include nasopharyngeal airway, laryngeal mask (LMA) or oropharyngeal airway. Exclusions: Inappropriate - patients with unknown GCS, patients without prehospital care, intubated patients prior to GCS calculation. Inclusions: n = all patients with first recorded GCS ≤ 8 at the scene.

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67 75

4426 17

33

568374

2013/2014 2014 2015 2016 2017

%Yes %No

Indicator Yes No 2017 n = 8 2 6 2016 n = 6 2 4 2015 n = 18 8 10 2014 n = 12 2 10 2013/2014 n = 19 5 14

Pediatric experts advise that it is best practice to move the injured pediatric patient from the scene quickly to acute care for intubation, if required, rather than attempt intubation at the scene. EMS evidenced-based protocols have LMA insertion as first attempt rather than endotracheal tube intubation. All patients are reviewed at the Pediatric Trauma Quality Management Committee to ensure appropriate care was given.


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3. Length of stay (LOS) at rural hospital greater than two hours.

Was the length of stay at a rural hospital > 2 hours? Exclusions: Inappropriate - patients had no first or second hospital. Unknown - missing arrival or departure time at first or second hospital Inclusions: n = all patients arriving at ACH from hospitals outside Calgary.

68

27 32

736773 60

27 33 40

2013/2014 2014 2015 2016 2017

%Yes %No

Indicator Yes No

2017 n = 19 13 6

2016 n = 11 8 3

2015 n = 25 15 10

2014 n = 30 20 10

2013/2014 n = 37 27 10

If at any time the Pediatric Trauma Quality Management Committee feels that the Rural Hospital LOS is not acceptable, communication to that hospital is sent for clarification of the timeline and appropriately followed up. The significant percentage of cases with a prolonged rural stay remains a concern and education around the importance of timely disposition and transfer of major trauma patients remains a priority. This is also an Alberta Trauma Services indicator that is being monitored across the Province. 4. Injury time to trauma centre < 4 hours for transferred patients.

Did the patient arrive at a trauma centre < 4 hours from the time of injury? Trauma Centre is defined as ACH, FMC, U of A, Royal Alexandra or Stollery Hospitals in Edmonton. As well as Red Deer, Lethbridge or Medicine Hat Hospitals. Exclusions: Out of the patient transfers, 3 patients were transferred from within Calgary, 4 from Lethbridge, 1 from Red Deer and 4 from Medicine Hat resulting in a total (n=8) of patients for this indicator. 2 patient had an unknown time of injury. Inclusions: n = all patients transferred from a non-trauma centre hospital with a known time of injury and known time of arrival.

38 50

87

50

3125 23

696275

2013/2014 2014 2015 2016 2017

%Yes %No

Indicator Yes No 2017 n = 8 4 4

2016 n = 8 1 7

2015 n = 16 5 11

2014 n = 13 5 8

2013/2014 n = 24 6 18

Half of the patients are still not seen at a Trauma Centre within the 4 hour timeline. Many factors contribute to delays, however, most are found to be related to challenges in mobilizing transfer of patients from rural health centers. RAAPID (Referral, Access, Advice, Placement, Information & Destination) protocols help mobilize transport more efficiently, while still not a mandatory service in Alberta, it is being used much more widely. This indicator has also been a priority for Alberta Trauma Services.


20

5. Utilization of ACH Transport team for transfer.

ACH Transport Team Utilization

Was the patient transported by the ACH Transport Team? Inclusions: n = all patients transferred from a primary or secondary hospital.

27

81 73

2430 26 19

767470

2013/2014 2014 2015 2016 2017

%Yes %No

Indicator Yes No 2017 n = 22 6 16

2016 n = 16 3 13

2015 n = 34 8 26

2014 n = 38 10 28

2013/2014 n = 43 13 30

The Alberta Children’s Hospital offers a specialized Pediatric Transport Team Service, which transports critically ill or injured children from referral centers located in southern Alberta, south-eastern British Columbia, and south-western Saskatchewan. The transport team travels by ambulance, helicopter or fixed-wing aircraft and provides quality pediatric critical care to the residents of these areas who do not otherwise have access to pediatric critical care specialists. Through RAAPID, medical control and mobilization of the team is achieved via the PICU attending physician. The team consists of a respiratory therapist (RT) and an ACH ED or PICU registered nurse (RN), with a physician on the team for difficult cases. Stabilization, if possible, is achieved prior to returning back to ACH, thus making the previous two indicators of ‘rural hospital LOS’ and ‘time to trauma centre’ longer on some occasions. All transport times are audited by the Trauma Coordinator and the Transport Team Clinical Nurse Specialist.


21

Resuscitative care: 6. Trauma Team Activation

Trauma Team Activation (Code 77) is the responsibility of the ED nurse answering the EMS patch phone using specific criteria that were developed by the Pediatric Trauma Committee. These include physiologic, anatomic and co-morbid factors, as well as mechanism of injury. The above graph illustrates Code 77 activation for the major trauma population only (ISS > 12). In the past year, the total Code 77 activations for all patients (regardless of ISS) was 67. ‘Overcall’ (those not admitted) was 21%. ‘Missed call’ (those that should have had an activation according to guidelines) was 3%. We also monitor for ‘undercalls’ (those patients that had significant injuries (ISS > 12, but did not meet activation criteria). In 2017 the undercall was 46% but upon review of each case there was nothing specific felt to be needed to add to the current criteria. The over, under and missed call is monitored closely by the Trauma Coordinator and reported monthly at the Trauma Committee.

Major Trauma Team Activation

23

5

34

54

3

11

5

22 21

34

10

21 1 1

23 3

21

3

12

10

43

1

34

11

32

6

3

1

3

01

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

# of

Act

ivat

ions

2014 2015 2016 2017


22

7. Direct Admission - Bypassed the Emergency Department (ED)

Direct Admission Exclusions: ED deaths Inclusions: n = all patients who were admitted to the trauma centre.

97 89

11366 14

94 94 86

2013/2014 2014 2015 2016 2017

%Yes %No

Indicator Yes No 2017 n = 46 5 41 2016 n = 39 1 38 2015 n = 66 9 57 2014 n = 96 6 90 2013/2014 n = 93 6 87

There is currently a No Direct Admit Policy for trauma patients – meaning they should stop in the ED for an assessment. This policy was made to ensure that every patient gets an unbiased, good primary survey. If a patient was admitted to a referral hospital for more than 24 hrs prior to the transfer this policy does not apply. This past year two patients were transferred postoperatively directly to ACH PICU. The other three patients were stabilized at referral centres and retrieved by the ACH Transport Team. These patients had a Trauma consult which ensures a Tertiary Trauma Survey is performed 24 hrs after admission. All cases are reviewed at the Trauma Quality Management Committee. 8. GCS < 8 at the trauma centre (TC) with mechanical airway intervention.

Did the patient with a first recorded trauma centre GCS < 8 receive a mechanical airway as an intervention in the ACH ED? Exclusions: Patients with GCS > 8 at ACH-ED. Inclusions: n = all patients with first recorded trauma centre GCS ≤ 8.

100100100 100100

2013/2014 2014 2015 2016 2017

%Yes %No

Indicator Yes No

2017 n = 3 3 0

2016 n = 1 1 0

2015 n = 2 2 0

2014 n = 4 4 0

2013/2014 n = 5 5 0

This past year, as in previous years, all patients that arrived at the ACH ED with a recorded GCS < 8 were appropriately intubated.


23

9. Presence of ED nursing documentation every one (1) hour.

After arrival at the trauma centre, was every (one) 1 hour documentation present on the ED record for the ED length of stay? Exclusions: Direct admits and unknown/missing ED notes. Inclusions: n = all patients seen in ED.

4079 69

21 31

39 49

61 60 51

2013/2014 2014 2015 2016 2017

%Yes %No

Indicator Yes No

2017 n = 42 29 13

2016 n = 39 31 8

2015 n = 57 28 29

2014 n = 90 36 54

2013/2014 n = 89 35 54

ED documentation continues to be a challenge and is considered to be important for patient care. There is ongoing education sessions for ED nurses throughout the year to help them become more aware of this necessary standard. 10. Presence of sequential neurological documentation in the ED for suspected head/spinal cord injuries

After arrival at the trauma centre, was sequential neurological documentation present on the ED record for the ED length of stay, if the patient had a diagnosis of skull fracture, intracranial injury, or spinal cord injury? Exclusions: Direct admits and unknown/missing ED notes. Inclusions: n = all patients seen in ED

73 73 827792

2723 278 18

2013/2014 2014 2015 2016 2017

%Yes %No

Indicator Yes No

2017 n = 34 28 6

2016 n = 33 24 9

2015 n = 48 44 4

2014 n = 74 54 20

2013/2014 n = 79 61 18

The Provincial Trauma Nursing Record used in the ED trauma room has one dedicated page for this documentation, however once the patient leaves the trauma room this record is no longer used. A separate neurological documentation record has been added to the ‘trauma pack’ documentation to help improve compliance.


24

11. Hypothermic in the ED (< 35.0 degrees C)

Was the patient hypothermic in the emergency department? Temperature was recorded at < 35.0 degrees C. Exclusions: Direct admits and unknown/missing ED temp. Inclusions: n = all patients seen in ED.

100 98

2033 2

97 97 98

2013/2014 2014 2015 2016 2017

%Yes %No

Indicator Yes No

2017 n = 42 1 41

2016 n = 37 0 37

2015 n = 57 1 56

2014 n = 89 3 86

2013/2014 n = 88 3 85

This past year one patient presented to the ED hypothermic and active rewarming occurred. 12. GCS < 12 in the TC with a CT head performed within 4 hours of trauma centre arrival (TCA).

Did the patient with a GCS < 12 receive a CT of the head within 4 hours of arrival at the ACH trauma centre? Exclusions: Inappropriate – GCS > 12, intubated patients arriving in ACH, Direct Admissions. Unknown – missing GCS documentation. Inclusions: n = all patients with a known ED GCS and a known time of CT head. 100 100100100 100

0

2013/2014 2014 2015 2016 2017

%Yes %No

Indicator Yes No

2017 n = 10 10 0

2016 n = 8 8 0

2015 n = 4 4 0

2014 n = 4 4 0

2013/2014 n = 19 19 0


25

13. Patient stay in ED less than 4 hours.

Did the patient have an ACH ED length of stay (LOS) < 4 hours at the ACH trauma centre? Exclusions: Direct Admissions and unknown ED LOS. Inclusions: n = all patients seen in ACH ED with a known ED LOS.

49 54 57

46 43

52 54

48 51 46

2013/2014 2014 2015 2016 2017

%Yes %No

Indicator Yes No

2017 n = 42 24 18

2016 n = 39 21 18

2015 n = 57 31 26

2014 n = 90 44 46

2013/2014 n = 89 46 43

ED LOS > 4 hrs continues to be a concern not only for trauma patients. All patients are reviewed to determine if there is a system or educational issue that can be addressed to decrease this time. ACH administration has taken measures to help increase capacity of the hospital overall. Alberta Trauma Services is monitoring this closely for all Trauma Centres in the province as it is a Trauma Accreditation Indicator. Definitive care: 14. Admission to a surgeon or intensivist.

Was the patient admitted to a surgeon or an intensivist at the ACH trauma centre? Exclusions: ED deaths. Inclusions: n = all patients admitted to ACH Trauma Centre.

91 829891 97

18 29 9 3

2013/2014 2014 2015 2016 2017

%Yes %No

Indicator Yes No

2017 n = 46 45 1

2016 n = 39 32 7

2015 n = 65 63 2

2014 n = 96 87 9

2013/2014 n = 93 85 8

This past year one patient was appropriately admitted to the Pediatric Service according to the Trauma Admission Guidelines.


26

15. Craniotomy within 4 hours after TCA with unstable epidural/subdural hematoma.

If the patient had an epidural or subdural brain hematoma, was a craniotomy performed within 4 hours of arrival at ACH trauma centre? Exclusions: Inappropriate – all patients without epidural or subdural hematoma. Inclusions: n = all patients with epidural or subdural hematoma where operative management was the planned intervention.

100 100 100 10071

29

2013/2014 2014 2015 2016 2017

%Yes %No

Indicator Yes No

2017 n = 8 8 0

2016 n = 1 1 0

2015 n = 2 2 0

2014 n = 3 3 0

2013/2014 n = 7 5 2

16. Missed cervical spine injury after 48 hours from TCA without maintaining spinal precautions.

Did the patient have a missed c-spine injury with spinal precautions removed at the ACH trauma centre? Exclusions: ED deaths. Inclusions: n = all patients admitted to ACH Trauma Centre.

100 10097 100 100

2013/2014 2014 2015 2016 2017

%Yes %No

3

Indicator Yes No

2017 n = 46 0 46

2016 n = 39 0 39

2015 n = 65 0 65

2014 n = 96 0 96

2013/2014 n = 93 3 90


27

17. Any laparotomy procedure performed.

Did the patient require a laparotomy? Exclusions: None Inclusions: n = all major trauma patients.

92 96

2 3 6 8 4

949798

2013/2014 2014 2015 2016 2017

%Yes %No

Indicator Yes No

2017 n = 47 2 45

2016 n = 40 3 37

2015 n = 66 4 62

2014 n = 96 3 93

2013/2014, n = 95 2 93

The small number of laparotomies performed this past year remains consistent with historical trends and continues to show the conservative management philosophy for blunt abdominal trauma in pediatrics. 18. Femur fracture to the OR within 24 hours of TCA.

Did the patient have operative management of the femur fracture within 24 hours of arrival at ACH trauma centre? Exclusions: No femur fracture or no surgical intervention planned. Inclusions: n = all patients requiring operative management of femur fracture.

100 10010010080

0 20

2013/2014 2014 2015 2016 2017

%Yes %No

Indicator Yes No

2017 n = 1 1 0

2016 n = 1 1 0

2015 n = 5 4 1

2014 n = 3 3 0

2013/2014 n = 3 3 0

Note that the total number of femur fractures is for ISS > 12 patients only – isolated femur fractures do not qualify as their ISS is 9.


28

19. Open long bone fracture to the OR after 6-12 hours from TCA (depending on the severity of the fracture).

Did the patient with open long bone fracture have operative management performed within 6 hours (grade 3) or 12 hours (grade 1, 2) of arrival to ACH trauma centre? The long bones include the radius, ulna, humerus, tibia, femur and fibula. Exclusions: No open long bone fractures; patients with open long bone #s but too unstable for operative repair within the timeframe; patients with open long bone #s who died within the timeframe. Inclusions: n = all patients requiring operative management of open fracture where grade of fracture is known. 00

100 100100

2013/2014 2014 2015 2016 2017%Yes %No

Indicator Yes No

2017 n = 1 1 0

2016 n = 1 1 0

2015 n = 0 0 0

2014 n = 1 1 0

2013/2014 n = 0 0 0

This patient had a very complicated open fracture as well as multiple other injures that needed stabilization prior to OR. This was deemed appropriate by the Trauma Quality Management Committee. 20. Unplanned return to the OR within 48 hours of initial procedure.

Did the patient have an unplanned return to the operating room at the ACH trauma centre? Exclusions: No operating room visit. Inclusions: n = all patients with at least one operating room visit.

100 90

104

100 96 100

2013/2014 2014 2015 2016 2017

%Yes %No

Indicator Yes No

2017 n = 21 2 19

2016 n = 15 1 14

2015 n = 23 0 23

2014 n = 28 1 27

2013/2014 n = 27 0 27

One of these patients needed to be taken back to the OR for a repeat orthopedic procedure as the first application was not promoting healing. The second needed to be taken back to the OR for a repeat neurosurgical intervention due to patient deterioration. Both of these cases were deemed appropriate as per the Trauma Quality Management Committee.


29

21. Missed injuries identified after 48 hours from TCA.

Did the patient have a delayed diagnosis or missed injury at the ACH trauma centre? Exclusions: ED deaths. Inclusions: n = all patients admitted to ACH Trauma Centre.

97 96

43224

989896

2013/2014 2014 2015 2016 2017

%Yes %No

Indicator Yes No

2017 n = 46 2 44

2016 n = 39 1 38

2015 n = 65 1 64

2014 n = 96 2 94

2013/2014 n = 93 4 89

A trauma tertiary survey (TTS) performed by the Trauma Surgery NP, Fellow or Resident at 24 hours of admission to the trauma centre helps to keep missed injuries to a minimum. However, in the past year there were two missed injury. One patient with multiple injuries had a clavicle fracture that was not recognized initially. The other patient with multiple injuries has an ankle fracture that was not recognized initially. Both cases were reviewed at the Trauma Quality Management Committee. 22. Reduction of joint dislocation/fracture dislocation after 1 hour from TCA.

If the patient had a joint dislocation or fracture dislocation (hip, shoulder, knee, elbow), was it reduced within first hour of TCA. Exclusions: No joint dislocation, died within first hour, wrist or ankle dislocations. Inclusions: n = all patients with joint dislocation or fracture dislocation who survived at least 1 hour.

100 100

000

2013/2014 2014 2015 2016 2017

%Yes %No

Indicator Yes No

2017 n = 0 0 0

2016 n = 0 0 0

2015 n = 1 1 0

2014 n = 1 1 0

2013/2014 n = 0 0 0


30

23. Revascularization of an ischemic limb within 6 hours from the time of injury.

If the patient had an ischemic limb, was it re-vascularized within 6 hours from the time of injury? Exclusions: No ischemic limb or patient died prior to repair. Inclusions: n = all patients with ischemic limb.

00000

2013/2014 2014 2015 2016 2017

%Yes %No

Indicator Yes No

2017 n = 0 0 0

2016 n = 0 0 0

2015 n = 0 0 0

2014 n = 0 0 0

2013/2014 n = 0 0 0

24. ORIF of facial fractures within 7 days of injury.

Did the patient with a facial fracture go to the operating room at ACH trauma centre within 7 days of injury? Exclusions: No major facial fractures or died prior to repair. Inclusions: n = all patients requiring operative management of major facial fractures who survive at least 7 days.

100

0

100100 100

2013/2014 2014 2015 2016 2017

%Yes %No

10

Indicator Yes No

2017 n = 1 1 0

2016 n = 0 0 0

2015 n = 1 1 0

2014 n = 3 3 0

2013/2014 n = 1 1 0


31

25. Operative repair of spinal fractures within 7 days of injury.

If the patient had an operative repair of spinal fractures, was it completed within 7 days of injury? Exclusions: No operative repairs or patient died prior to repair. Inclusions: n = all patients with operative repair of spinal fracture who survive at least 7 days.

00

100100100

2013/2014 2014 2015 2016 2017

%Yes %No

Indicator Yes No

2017 n = 0 0 0

2016 n = 0 0 0

2015 n = 4 4 0 2014 n = 1 1 0

2013/2014 n = 2 2 0

26. Pelvic ring fracture / acetabular fracture (with hemodynamic instability) provisional stabilization > 6 hours of TCA.

If the patient had an operative repair of pelvic fractures, was it completed > 6 hours after arrival? Exclusions: No operative repairs or patient hemodynamically stable. Inclusions: n = all patients with operative repair of pelvic fractures with hemodynamic instability.

1000000

2013/2014 2014 2015 2016 2017

%Yes %No

Indicator Yes No

2017 n = 1 0 1

2016 n = 0 0 0

2015 n = 0 0 0

2014 n = 0 0 0

2013/2014 n = 0 0 0


32

27. Definitive treatment of displaced acetabular fracture > 7 days of TCA.

If the patient had an operative repair of pelvic fractures, was it completed > 7 days of arrival? Exclusions: No operative repairs or patient hemodynamically unstable. Inclusions: n = all patients with operative repair of displaced acetabular fractures.

0 0 00 0

2013/2014 2014 2015 2016 2017

%Yes %No

Indicator Yes No

2017 n = 0 0 0

2016 n = 0 0 0

2015 n = 0 0 0

2014 n = 0 0 0

2013/2014 n = 0 0 0

28. Unplanned PICU admission or re-admission.

Did the patient have an unplanned admission to ICU at the ACH trauma centre? Exclusions: ED deaths. Inclusions: n = all patients admitted to ACH Trauma Centre.

97 98

232

10010098

2013/2014 2014 2015 2016 2017

%Yes %No

Indicator Yes No

2017 n = 46 1 45

2016 n = 39 1 38

2015 n = 65 0 65

2014 n = 96 0 96

2013/2014 n = 93 2 91

This year a patient was appropriately transferred to the PICU after deterioration on the inpatient unit.


33

Did the patient have an unplanned readmission to ICU at the ACH trauma centre? Exclusions: Patients without admission to ICU. Inclusions: n = all patients with at least one ICU admission.

100

44

96100100 96

2013/2014 2014 2015 2016 2017

%Yes %No

Indicator Yes No

2017 n = 23 1 22

2016 n = 16 0 16

2015 n = 28 1 26

2014 n = 33 0 33

2013/2014 n = 39 0 39

The PICU Specialized Transitional Educational Personnel (STEP) team follows patients that are transferred out of the PICU to ensure safety; this past year one patient was re-admitted to the PICU after the STEP team was activated from the in-patient unit due to patient deterioration. Outcome: 29. Death during the first 24 hours of TCA.

Did the patient die within the first 24 hours of admission to the ACH trauma centre? Exclusions: All patients who survived. Inclusions: n = all patients who died.

17 33 25

67 75

60 67

40

83

33

2013/2014 2014 2015 2016 2017

%Yes %No

Indicator Yes No

2017 n = 4 1 3

2016 n = 3 1 2

2015 n = 9 6 3

2014 n = 6 1 5

2013/2014 n = 5 3 2

This past year one patient died in the ED after a submersion injury. An additional 3 patients died in the PICU after 24 hours; one due to a submersion injury, one from hanging and the other from non-accidental trauma causing a catastrophic head injury. All death cases were reviewed by the Trauma Quality Management Committee and care was deemed appropriate.


34

30. Did the patient die in ACH?

Did the patient die? Exclusions: None. Inclusions: n = all trauma patients arriving at ACH trauma centre.

92 91

9865 14

95 94 86

2013/2014 2014 2015 2016 2017

%Yes %No

Indicator Yes No

2017 n = 47 4 43

2016 n = 40 3 37

2015 n = 66 9 57

2014 n = 96 6 90

2013/2014 n = 95 5 90

ACH Major Trauma Statistics (ISS>12) 2017

35

APPENDIX B Major Trauma Statistics for 2017

1. General Overview Age Gender

2. Etiology of Injuries Mechanism of Injury Type of Injury Place of Injury

3. Referrals and Emergency Management Referrals from Health Regions Mode of Transportation to ACH Ground vs Air Transport ED Arrival By Month, Day and Time of Arrival Diagnostic Imaging Statistics Day of Week and Time of CT Non-Operative Procedures Performed in ED Patient Disposition from ED

4. In-Patient Care Management and Outcomes Surgical Procedures OR Data by Service Time to OR Length of Stay Admitting Physician Service Hospital Discharge Destination Trauma Readmissions Outcomes by Age and ISS TRISS Pre-Charts


36

1. General Overview Table 1. ACH Major Trauma Statistics – Five-year Trend Analysis Data Source: Alberta Trauma Registry at ACH

2013/2014 2014 2015 2016 2017 Total Patients

95 96 66 40 47

Males

57 60.0%

59 61.4%

31 47.0%

30 75.0%

36 76.6%

Females

38 40.0%

37 38.5%

35 53.0%

10 25.0%

11 23.4%

Total Length of Stay (LOS) (days)

765 827 1078 387 516

Median LOS

5 5 5 5 4

Mean LOS

8 9 16 10 11

Total Emergency Department (ED) LOS (hours)

402.9 390.5 234.8 160.1 134.1

Median ED LOS (hours)

3.5 4.0 3.5 3.5 3.0

Mean ED LOS (hours)

4.3 4.3 4.1 4.0 3.1

ICU Admissions

39 41.0%

33 34.3%

28 42.4%

16 40.0%

23 48.9%

Median ICU LOS (days)

2 2 3 5 4

Mean ICU LOS (days)

3 4 6 7 5

Total ICU LOS (days)

125 143 179 109 118

Median ISS

19 18 21 17 21

Mean ISS

24 22 23 21 22

Direct Admits

6 6 9 1 5

Referrals to ACH from other centres

43 45.2%

38 39.6%

34 51.5%

16 40.0%

22 46.8%

Deaths 5 5.2%

6 6.3%

9 13.6%

3 7.5%

4 8.5%

In 2017, 47 major trauma patients (meeting criteria for inclusion in the trauma registry) were seen

at the ACH. This volume is lower than the five-year average of 69 major trauma patients seen annually. This decrease was noticed in 2015 and was felt to be due to upgrading to the AIS 2005 coding system on


37

January 1, 2015 in order to prepare for submission to the National Trauma Data Bank based in the US in the near future. We would like to also speculate that pediatric trauma numbers are lower in Southern Alberta due to Injury Prevention awareness campaigns.

This 2017 trauma volume represents 6.4% of all patients admitted to the ACH with injuries

(n=732), which is a 1% increase from last year. The percentage of major trauma patients who are males (76.6%) were greater than females

(23.4%). Total LOS for major trauma patients ranged between 1 and 80 days. Median LOS of 4 days is

consistent with the five-year trend of 5. Mean LOS of 11 days is equal to the five-year trend of 11. The total ED LOS was 134.1 hours, and lower than the five-year average of 264.5 hours. The

median LOS of 3.0 is slightly lower than the five-year average of 3.5. The mean LOS of 3.1 is lower than the five-year average of 4.

48.9% of major trauma patients were admitted to the ICU, which is higher than the five-year

average of 41.3%. Total ICU LOS was 118 days, which is lower than the five-year average of 135. The median (4) is lower that the five-year average of 3.2 and the mean ICU LOS (5) is equal to the five-year average of 5.

The median ISS (21) for major trauma patients in 2017 was higher than the five-year average of

19.2. The mean ISS (22) was consistent with the five-year average of 22.4. Major trauma patients referred in from other centers represented 46.8% of the major trauma

volume for 2017. This is slightly higher than the five-year average of 44.6%. A total of 4 deaths were seen in major trauma patients in 2017. This represents 8.5% of major

trauma volume, and is consistent with the five-year average of 8.2%.


38

Figure 1. Age and Gender Distribution for ACH Major Trauma Patients for 2017

Figure 1 shows the number of males and females for the above age groups. In 2017 the majority of trauma patients were male. On average males comprised 64% of the major trauma population over a period of five years. Figure 2a. Age Distribution of <15 year olds admitted to Calgary Adult Hospitals

2

5

12

10

7

0

32

6

00

2

4

6

8

10

12

14

<1 1 to 4 5 to 9 10 to 14 >14

# of

Pat

ient

s

Age Groups

Male Female

2014 2015 2016 2017FMC 0 0 1 0PLC 2 0 0 0RGH 1 0 0 0SHC 0 1 0 0

0

1

2

3

4

5

# of

Pat

ient

s

<15 year old Major Trauma Patients


39

Figure 2b. Age Distribution of 15 to 17 year olds admitted to Calgary Hospitals

Figure 2b shows the number of major trauma patients aged 15-17 admitted to Calgary Hospitals over the past five years. Current Alberta Health Services guidelines state that major trauma patients 15-17 years of age should be transported to and treated at the Foothills Medical Centre (FMC). However, if a patient in this age group arrives at ACH they will be treated.

2013/2014 2014 2015 2016 2017ACH 3 8 8 6 7FMC 37 24 43 29 13PLC 0 0 0 0 0RGH 0 0 0 0 0SHC 0 0 0 0 0

05

101520253035404550

# of

Pat

ient

s15 to 17 year olds Major Trauma Patients


40

2. Etiology of Injuries

Mechanism of Injury (MOI) describes the nature of the injury; transportation, falls, violence, and other mechanisms of injury. Figure 3. Breakdown by Mechanism of Injury

. Figure 3 shows the breakdown of the mechanism of injuries for the incidents in 2017 as compared to the historical trend. The biggest change this past year was a slight increase in violence related injuries and a decrease in falls.

Transport41%

Falls27%

Violence6%

Other26%

2007/2008 - 2011/2012

Transport34%

Falls19%

Violence17%

Other 30%

2017

Transport42%

Falls28%

Violence10%

Other20%

2013/2014 - 2016


41

Mechanism of Injury – Transportation Figure 4. Transportation Statistics

Figure 4 shows the breakdown of transportation-related injuries in 2017 as compared to the historical trend. There was a significant increase in motorized recreational vehicle (MRV) mechanism and a decrease in motor vehicle collision (MVC) this past year. A total of 16 patients (34% of major trauma patients) were involved in transportation-related incidents in 2017.

Mortality: 0% No patients died. ISS ranged from 14 to 45. Mean ISS was 23 and median ISS was 21.

Figure 5. Five-Year Trend for Transportation as the MOI

Figure 5 shows a 9% decrease in transportation-related incidents from 2016.

44%

29%

50%43%

34%

0%10%20%30%40%50%60%

2013/2014 2014 2015 2016 2017

% o

f Pat

ient

s

Years

MOI -Transportation

MVC19%

Pedestrian25%

Cyclist 25%

MRV 31%

2017

MVC37%

Pedestrian25%

Cyclist25%

MRV13%

2013/2014 - 2016


42

Figure 6. Transportation by Age Group

Figure 6 shows the breakdown of transportation incidents by age groups in 2017 as compared to the historical trend. No patients <1, 1 to 4 or >14 yr olds were seen in this category.

In 2017: Age Group <1 (n=0) no patients in this age group. Age Group 1-4 (n=0) no patients in this age group. Age Group 5-9 (n=6, 37%) included 1 passenger, 2 pedestrians, 1 cyclist and 2 ATV related injuries. Age Group 10-14 (n=10, 63%) 2 passengers, 3 cyclists, 2 pedestrians and 3 ATV related injuries. Age Group > 14 (n=0) no patients in this age group.

5 to 937%

10 to 14

63%

2017

<12% 1 to 4

14%

5 to 931%

10 to 14

44%

>149%

2013/2014 - 2016


43

Mechanism of Injury – Falls Figure 7. Statistics for Falls as the MOI Figure 7 shows the breakdown of fall incidents in 2017 as compared to the historical trend. There has been a 29% increase in same-level falls and a 29% decrease in multi-level falls.

A total of 9 patients (19% of major trauma patients) were admitted for fall-related injuries.

Mortality: 0% all patients survived. ISS ranged from 14 to 30. Mean ISS was 22 and the median ISS was 21.

Figure 8. Five-Year Trend for Falls as the MOI

Figure 8 shows the comparison of falls as the mechanism of injury over the past five years. This past year there was a 4% decrease which is well below the five year average of 25%.

28%

35%

18%

23%19%

0%

5%

10%

15%

20%

25%

30%

35%

40%

2013/2014 2014 2015 2016 2017

% o

f Pat

ient

s

MOI Falls

Multi-Level56%

Same-Level44%

2017

Multi-Level85%

Same-Level15%

2013/2014 - 2016


44

Figure 9. Falls by Age Group

Figure 9 shows the breakdown of fall incidents by age groups in 2017 as compared to the historical trend. No patients <1 were seen this year. A significant increase is seen in the >14 and 1-4 age groups and there was a decrease in the 5-9 age group.

In 2017: Age Group <1 (n=0) No patients in this age group. Age Group 1-4 (n=3, 34%) included 3 multi-level falls, involving two falls from second storey windows

and a fall from a shopping cart. Age Group 5-9 (n=2, 22%) included 2 multi-level falls, involving a fall from a second storey window

and a fall from a bunk bed. Age Group 10-14 (n=2, 22%) included 2 same-level falls, one off a toboggan and one while playing

sports. Age Group >14 (n=2, 22%) included 2 same-level falls involving skateboards.

1 to 434%

5 to 922%

10 to 1422%

>1422%

2017

<119%

1 to 421%

5 to 930%

10 to 1424%

>146%

2013/2014 - 2016


45

Mechanism of Injury – Violence Figure 10. Violence as the MOI Figure 10 shows the breakdown of violence-related incidents in 2017 as compared to the historical trend. Note the 18% increase in unarmed assault and the slight increase in the self-inflicted category.

A total of 8 patients (17% of major trauma patients) were admitted for violence-related injuries.

Mortality: 25% two patients died. ISS ranged from 14 to 30. For survivors, the mean ISS was 24 and the median ISS was 25. For non-survivors, the mean and median ISS were both 26.

Figure 11. Five-Year Trend for Violence as the MOI

Figure 11 shows a 7% increase in violence related injuries in the past year, which is above the five year average of 12%.

9%

15%

11% 10%

17%

0%

5%

10%

15%

20%

2013/2014 2014 2015 2016 2017

% o

f Pat

ient

s

MOI - Violence

Unarmed assault

25%

Self-inflicted

12%

Other & Unspecified

50%

Assault with

object13%

2017

Unarmed assault

7%

Self-inflicted

10%Other & Unspecified

66%

Assault with

Object17%

2013/2014 - 2016


46

Figure 12. Violence Incidents by Age Group

Figure 12 shows the breakdown of violence incidents by age groups in 2017 as compared to the historical trend. There was a large increase in the 5-9 and >14 age categories, with a significant decrease in <1 age group.

Age Group <1 (n=2, 25%) 2 non-accidental trauma or intentional injury in this age category. Age Group 1-4 (n=2, 25%) 2 non-accidental trauma. There was one death in this age category. Age Group 5-9 (n=1, 12%) Assault with an object. Age Group 10-14 (n=1, 13%) Self-inflicted injury resulting in death. Age Group >14 (n=2, 25%) 2 unarmed assaults in this age category.

<125%

1 to 425%5 to 9

12%

10 to 1413%

>1425%

2017

<141%

1 to 426%

5 to 96%

10 to 1415%

>1412%

2013/2014 - 2016


47

Mechanism of Injury – Other Figure 13. Statistics for Other Mechanism of Injury

Figure 13 shows the breakdown of other mechanism of injuries in 2017 as compared to the historical trend. There were no fire & explosion or other/unspecified injuries this year. A total of 14 patients (30% of major trauma patients) were admitted for other mechanism of injuries.

Mortality: 14% two patients died. ISS ranged from 14 to 25. For survivors, the mean ISS was 18 and the median ISS was 17. For non-survivors, the mean and median ISS were both 25.

Figure 14. Five-Year Trend for Other Mechanism of Injury

Figure 14 shows a 7% increase in the number of patients whose injuries are caused by animal, burn, inhalation, submersion injury, and mechanical-related incidents when compared to the five year average of 23%.

18%21% 21%

25%30%

0%5%

10%15%20%25%30%35%

2013/2014 2014 2015 2016 2017

% o

f Pat

ient

s

MOI - Other

Animal 22%

Mechanical57%

Submersion & Drowning

14%

Inhalation & Ingestion

7%

2017

Animal 23%

Mechanical51%

Submersion & Drowning

11%

Inhalation & Ingestion

2%

Fire & Explosion

6%

Other & Unspecified

19%

2013/2014 - 2016


48

Figure 15. Other Mechanism by Age Group

Figure 15 shows the breakdown of incidents involving other mechanism of injury by age groups in 2017 as compared to the historical trend. There was an increase in both the 5-9 and >14 age categories and there were no patients in the <1 age category this year. In 2017: Age Group <1 (n=0) No patients in this age category. Age Group 1-4 (n=3, 21%) included 1 mechanical power tool injury, 1 animal-related injury and 1

drowning resulting in death. Age Group 5-9 (n=5, 37%) included 1 mechanical machinery injury, 2 striking or struck by object or

persons in sports, 1 animal-related injury and 1 drowning resulting in death. Age Group 10-14 (n=3, 21%) included 1 striking or struck by objects or persons in sports, 1 animal

related injury and 1 inhalation injury. Age Group >14 (n=3, 21%) included 2 striking or struck by object or persons in sports and 1 striking

against or struck by objects or persons in non-sports.

1 to 421%

5 to 937%

10 to 1421%

>1421%

2017

<12%

1 to 428%

5 to 929%

10 to 1433%

>148%

2013/2014 - 2016


49

Type of Injury

Type of Injury indicates whether the most serious injury is blunt, penetrating, burn, or other type of injury (submersions and drownings). Figure 16. Type of Injury

Figure 16 shows the different types of injuries sustained by the major trauma patients in 2017. Blunt injuries comprised 83% of major trauma population. More penetrating injuries with ISS > 12 were seen this year. Note that submersion is reported as ‘other’. Figure 17. Five-Year Trend for Type of Injury

Figure 17 compares the different types of injuries from 2013/2014 up to 2017.

39

5 0 30

50

100

Blunt Penetrating Burn Other

Type of Injury - 2017Total Pts = 47


90 88

62

35 39

3 3 1 3 51 2 0 1 01 3 3 1 30

20

40

60

80

100

2013/2014 2014 2015 2016 2017

# o

Patie

nts

Fiscal Years

Type of Injury - Five Year TrendTotal Pts = 344



50

Figure 17b. Penetrating Trauma All ISS

On April 1, 2012 all AHS trauma centers began capturing data on all penetrating traumas regardless of ISS in the Alberta Trauma Registry. In 2017 there were 21 penetrating traumas. More than double the five year average of 9. Severe dog bites made up the majority of these cases. Place of Injury Figure 18. Statistics for Place of Injury

Figure 18 shows where the patients were injured in 2017 as compared to the historical trend.

9 74 4

21

0

10

20

30

40

50

2013/2014 2014 2015 2016 2017

# of

Pat

ient

s

Fiscal Years

Penetrating Trauma All ISS

Home/Res Inst32%

Other13%Public

Building8%

Recreation17%

Street17%

Unspecified13%

2017

Farm1%

Home/Res Inst31%

Other8%

Public Building

4%

Recreation13%

Street34%

Unspecified9%

2013/2014 - 2016


51

3. Referrals and Emergency Management Referral Patterns

Out of 344 major trauma patients from 2013/2014 to 2017, a total of 153 patients (45%) were referred to ACH by other hospitals.

The highest number of out of region referrals to ACH was made by Lethbridge Regional Hospital with a total of 18 patients (12% of total referrals) and Medicine Hat Regional Hospital with a total of 15 patients (10% of total referrals) over five years. Red Deer, Cranbrook and South Health Campus in Calgary also continue to be major referral centres.

Note that the province of Alberta no longer has specified health regions. All are now classified as Alberta Health Services, however the below transfer summary continues to report in the regions for historic consistency. Table 2. Transfers from Other Centres by Health Region

Region Hospital 2013/2014 2014 2015 2016 2017 Total Region 1 - Chinook Health Region, Total = 32 Blairmore - Crowsnest Pass 2 2 Cardston – Municipal 3 1 4 Fort Macleod H.C.C. 1 3 4 Lethbridge Regional 5 5 4 4 18 Pincher Creek Municipal 1 1 Taber H.C.C. 1 1 1 3 Region 2 - Palliser Health Region, Total = 18 Brooks Health Centre 1 1 1 3 Medicine Hat Regional 3 5 1 2 4 15 Region 3 - Calgary Health Region, Total = 51 Banff - Mineral Springs 1 3 1 5 Black Diamond – Oilfields General 1 1 1 3 Calgary – Foothills 1 1 2 2 6 Calgary – General/Peter Lougheed 1 2 3 1 1 8 Calgary – Rockyview General 1 4 1 6 Calgary – South Health Campus 3 1 3 2 1 10 Calgary – Sheldon M. Chumir Centre 1 1 Calgary - South Calgary Health Centre 1 1 Canmore General 1 1 2 4 Claresholm General 1 1 2 High River General 1 1 Strathmore - Valley General 3 3 Cochrane Urgent Care 1 1


52

Region 4 - David Thompson Health Region, Total = 30 Didsbury – Mountain View H.C. 1 1 2 Drumheller Regional 1 1 2 Hanna H.C.C. 1 1 Olds General 1 1 Red Deer Regional 4 6 2 1 1 14 Rocky Mountain House 2 1 3 Stettler General 1 1 2 Sundre General 1 1 Three Hills H.C.C. 1 1 1 1 4 British Columbia, Total = 22 Cranbrook Regional Hospital 5 5 1 2 13 Elkford Health Centre 1 1 Fernie District Hospital 3 1 1 5 Invermere District Hospital 1 1 2 Penticton Regional Hospital 1 1 Saskatchewan, Total = 0 Out of Country, Total = 0


53

Mode of Transport for Patients Arriving at ACH Figure 19. Direct from the Scene

Figure 19 shows the patients arriving at ACH ED directly from the scene in 2017 as compared to the historical trend. Note the increase in helicopter transports for direct from the scene patients.

Figure 20. Referrals

Figure 20 shows the patients who were referred to ACH for further treatment in 2017 as compared to the historical trend. Note the increase in helicopter and fixed-wing transports and the decrease in ground transports. The appropriateness of the means of transport is part of the review process for each major trauma patient.

Ground 60%

Helicopter24%

Private/Walk-in16%

2017

Ground 61%Helicopter

13%

Private/Walk-in26%

2013/2014 - 2016

Ground46%

Helicopter27%

Fixed-wing27%

2017

Ground 61%

Helicopter18%

Fixed-wing20%

Private/Walk-in1%

2013/2014 - 2016


54

Figure 21. Ground vs Air

Ground ambulance transported 25 patients (53%) major trauma patients in 2017, which is slightly lower than the previous year. Their ISS was a mean of 22 and median of 21. Patients transported by air also had an ISS mean of 22 and median of 21. Month and Time of Arrival Figure 22. Month of Arrival

There was a decrease in major trauma patients arriving in ACH ED in all months except January, March and April in 2017 as compared to the historical trend. Note that no major trauma patients were seen at ACH in December and a significant decrease over the summer months as well.

0%

10%

20%

30%

40%

50%

60%

70%

2013/2014 2014 2015 2016 2017

Ground vs Air

Ground

Air

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov DecMean 13/14-16 2.8 7.3 2.8 4.3 7.8 7.0 8.5 11.8 5.5 4.8 5.3 6.52017 7 3 3 5 4 6 2 4 5 3 5 0

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

Comparison of ED Arrival by Month for 2017 with 2013/2014 to 2016


55

Figure 23. Day of Arrival

In 2017, there was a decrease in major trauma patients arriving in ACH ED all days, when compared to previous years, due to decreased number of overall patients seen. Saturday was the busiest day of the week in 2017. Time of Arrival Figure 24. Time of Arrival

Figure 24 shows marked decreases in all time categories, but still showing that the majority of patients arrive between 16:01-24:00.

Sun Mon Tues Wed Thu Fri SatMean 13/14 - 16 14.5 9.0 6.3 10.3 9.5 11.3 13.32017 8 8 6 6 6 4 9

0.02.04.06.08.0

10.012.014.016.018.0

Comparison of Arrival by Day for 2017 with 2013/2014 - 2016

00:01-08:00 08:01-16:00 16:01-24:00Mean 13/14 -16 8.3 21.8 44.32017 6 16 25

0.0

10.0

20.0

30.0

40.0

50.0

Comparison of Time of Arrival for 2017 with 2013/2014 - 2016


56

Figure 25. Time of Arrival of Patients Arriving Directly from the Scene

Figure 25 shows the patients that arrive at ACH directly (without going to another medical facility), the majority arrived between 08:01-16:00 which is different than the historical trend.

Diagnostic Imaging Performed in 2017 Table 3. Diagnostic Imaging A total of 30 patients (64% of major trauma patients) went urgently (within 6 hours of arrival) to CT for imaging of the following body locations. This is lower than the 5 year average of 72% for urgent CTs for major trauma patients.

Diagnostic Imaging CT Locations

# Patients Percent of Total Patients (n=30)

Percent of Positive Results

Head 21 70% 95% Abdomen 15 50% 47% Pelvis 15 50% 47% Spine 21 70% 19% Chest 7 23% 43% Face 4 13% 100%

Note: Some patients had CTs done on multiple body locations. Also note some patients had CTs done at referral centre prior to coming to ACH. Note the percentage of positive results of the various body parts.

00:01-08:00 08:01-16:00 16:01-24:00Mean 13/14 - 16 1.8 15.5 24.32017 1 13 11

0.0

5.0

10.0

15.0

20.0

25.0

30.0

Comparison of Patients Arriving Directly From the Scene for 2017 with 2013/2014 -2016


57

Figure 26. Time of Day of Urgent CT

Figure 26 compares the time of urgent CTs from 2013/2014 to 2017. Note the consistency that the majority of urgent CTs are performed between 16:01-24:00 which is when the majority of major trauma patients arrive at the ACH ED. In 2017, 63% (n=19) of patients had CTs done from 16:01 to midnight. Only 10% of patients had CT’s from midnight to 8:00 AM and 27% of patients had CT’s from 08:01 to 16:00.

Figure 27. Day of the Week CT performed

Figure 27 compares the day of the week CT was performed from 2013/2014 to 2017. In 2017 there is an increase in the CT’s performed on Mondays, Wednesdays and Saturdays compared to 2016.

6

19

49

5

20

39

6

16

26

3 2

26

38

19

0

10

20

30

40

50

60

00:01-08:00 08:01-16:00 16:01-24:00

# of

Pat

ient

s

Time of Day

Time of Day of Urgent CT (within 6 hours of arrival, n=30)

2013/2014 2014 2015 2016 2017

8

57 7

16

21

1011

4

14

4

8

17

68

3 4

11

6 5

11

2 3 3

7

3 2

11

6

2

5 42

6 5

0

5

10

15

20

25

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

# of

Pat

ient

s

Day of the Week CT Performed

2013/2014 2014 2015 2016 2017


58

Figure 28. CT done within 1 hour of ED Arrival

Figure 28 shows the past five years comparisons if CT was done within one hour of arrival at ACH ED. In 2017 33% of patients did not have a CT done within this timeframe. Time to CT scan is reviewed at the Trauma Quality Management Committee for all major trauma patients and recommendations are made for individual cases. Of note, the staff Radiologists at ACH have committed to reading and reporting all Code 77 CT scans within one hour of the scan, however, not all major trauma patients meet criteria for a Code 77. Non-Operative Procedures Performed in 2017 Table 4. Non-operative Procedures Performed on Patients while in ACH ED

Non-Operative Procedures # Patients Percent of Total Patients (n=42)

Gastric Tube Insertion 7 17% Foley Catheter Insertion 7 17% Intubation 5 12% Blood Product Administration 5 12% Chest Tube Insertion 0 0% Pelvic Binder Application 1 3%

Many patients have these types of non-operative procedures done at referral centres prior to transport, so are therefore not represented in this table.

0

10

20

30

40

50

60

2013/2014 2014 2015 2016 2017

# of

Pat

ietn

s

Year

CT within 1 hour of ED Arrival

Yes

No


59

Patient Disposition from ED Figure 29.

Figure 29 shows the breakdown of patient disposition from the ED in 2017 as compared to the historical trend. This past year, there was a significant increase in OR/ICU when compared to the past five years. There was one ED death in 2017.

4. In-Patient Care Management and Outcomes Surgical Procedures Table 5. Five-Year Trend

2013/2014 2014 2015 2016 2017 Total Major Trauma Patients 95 96 66 40 47 Total Patients Requiring Surgery 27 27 22 15 21 Total OR Visits 31 52 29 27 51 Total OR Hours 80 130 63 57 110 Mean (hours per case) 2.7 2.5 2.8 2.1 5.2 Mean (visits per case) 1 2 1 2 2

In 2017 15 (45%) of trauma patients went to the OR. This is higher than the 5 year average of 34%. Note the total OR hours have significantly increased this past year as compared to 2016, and are well above the 5 year average of 88. This year five patients alone accounted for over half of the OR visits and over 52 OR hours.

Died in ED2%

ICU8%

OR/ICU30%

OR/Ward4%

Direct Admit11%

Ward45%

2017

Died in ED1%

ICU28%

OR/ICU6%

OR/Ward3%

Direct Admit

8%

Ward54%

Died in OR0.3%

2013/2014 - 2016


60

Figure 30. Total Patients Requiring Surgery

Figure 30 shows a 7% increase in the number of patients requiring surgery, compared to 2016.

Table 6. OR Data by Service

OR Data by Service - 2017

Physician Service # of Procedures Neurosurgery 11 Orthopedics 6 Pediatric General Surgery 21 Plastics 18 Vascular Surgery 1 Urology 2

Table 6 shows the physician services that performed the surgical procedures. During some procedures there were multiple physician services in the OR at one time.

28% 28%33%

38%

45%

0%

10%

20%

30%

40%

50%

2013/2014 2014 2015 2016 2017

# of

Pat

ient

s Total Patients Requiring Surgery


61

Figure 31. Time of Day to OR

Figure 31 compares the time patients went to the OR from 2013/2014 to 2017. In 2017, the majority of patients went to OR between 16:01 - 24:00. Length of Stay Statistics Figure 32. Patient LOS

Figure 32 compares the hospital admission LOS of patients from 2013/2014 to 2017. In 2017, the median LOS for all patients was 4 days - consistent with the previous 5 year average of 5 days. A majority of patients (66%) stayed between 1 and 6 days, while 34% of patients stayed between 7 and 98 days.

2

16

9

3

9

15

0

14

8

2

6 7

1

6

14

0

5

10

15

20

00:00 -08:00 08:01 - 16:00 16:01 - 24:00

Time of Day to OR

2013/20142014201520162017

0%

10%

20%

30%

40%

50%

1-3 4-6 7-12 13-60 61-98 99-206Perc

entil

e of

Pat

ient

s

Number of Days

LOS by Percentile of Patients

2013/2014

2014

2015

2016

2017


62

Admitting Physician Service Analysis – 2017 Table 7.

In 2017, a total of 23 patients (50%) were initially admitted to ICU. Those patients were subsequently transferred to the following:

8 patients went to Neurosurgery 4 patients went to Pediatrics 5 patients went to General Surgery 2 patients went to Plastic Surgery 3 died in ICU 1 transferred to U of A Stollery Children’s Hospital

2 patients were transferred into the ICU from the in-patient units.

Both patients were transferred back to General Surgery

Physician Service # Patients Initially

Admitted to

Service

Percent of Total

Patients Admitted n=46 (1

ED death)

# Patients Trans-

ferred to Service

Total Trauma Cases

per Service

Total Days

on Service

Mean LOS on Service

Median LOS on Service

ICU 23 50% 2 25 118 5 4 Neurosurgery 5 11% 8 13 29 2 2 Orthopedics 1 2% 0 1 4 4 4 Pediatrics 1 2% 4 5 142 28 12 General Surgery 16 35% 5 21 208 10 3 Plastic Surgery 0 0% 2 2 19 10 10


63

Hospital Discharge Destination Figure 33. Discharge Destinations

Figure 33 shows that most patients went home or home with support services in 2017. Figure 34. Trauma Readmissions to ED

Figure 34 shows the unplanned return to ED within 30 days of discharge from a major trauma. This is the first year for collection of this data. In 2017 there were 3 patients that returned to ED but did not require re-admission. Two patients returned to ED for advice on irritability, poor feeding and poor sleeping post traumatic brain injury – no treatment was given. The third patient was brought back to the ED almost one month post discharge with viral gastroenteritis – no treatment was given. It was felt that the advice given to all these patients on their major trauma discharge was adequate. In 2017 there were no patients that had an unplanned return to ED within 30 days of discharge that required admission.

AnotherAcute Care

Facility

Children'sAid/Foster

CareDied Home

Home withSupportServices

Other RehabFacility

Mean 13/14 - 16 2.5 3.3 5.8 49.3 13.3 0.0 0.32017 1 2 4 28 12 0 0

0.010.020.030.040.050.060.0

Comparison of Discharge Destination for 2017 with 2013/2014 - 2016

0

1

2

3

4

5

2017

# of

Pat

ient

s

Year

Trauma Readmissions to ED within 30 Days of Discharge


64

Outcomes by Age Figure 36. Survivors

Figure 34 compares all age groups of survivors. Figure 37. Non-Survivors

Figure 35 shows 4 deaths in 2017. Two children, ages 3 and 6 years died from drowning. A 13 year old died from asphyxia with cardiac arrest due to hanging and a 3 year old died from severe head injuries resulting from non-accidental trauma.

< 1 1-4 5-9 10-14 > 14Mean 13/14 -16 7.8 12.8 19.5 22.8 5.82017 2 6 13 15 7

0.0

5.0

10.0

15.0

20.0

25.0

Comparison of Survivors by Age Group for 2017 with 2013/2014 - 2016

< 1 1-4 5-9 10-14 > 14Mean 13/14 - 16 1.0 1.8 1.0 1.5 0.52017 0 2 1 1 0

0.0

0.5

1.0

1.5

2.0

2.5

Comparison of Non-Survivors by Age group for 2017 with 2013/2014 - 2016


65

Outcomes by ISS Figure 38. Survivors vs Non-Survivors by ISS

Most survivors (70%, n=43) had an ISS from 16 to 25. Non-survivors were in the ISS ranges 16-25 and 26-35, with a 75% and 25% mortality rate respectively.

5

30

62 00

3 1 0 005

101520253035

12 - 15 16 - 25 26 - 35 36 - 45 45 +

# of

Pat

ient

s

ISS

2017

Survivors Non-Survivors


66

TRISS Pre Charts for 2017 The following charts identify patients according to their probability of survival (Ps). Each patient is characterized by the Revised Trauma Score (RTS) and the Injury Severity Score (ISS) and then plotted on a graph. The shaded area represents the combination of the RTS and the ISS which yield a probability of survival (Ps) of >.50. The area above the line represents a probability of survival of <.50. Patients who are above the shaded area and survive and those who die and are plotted in the shaded area are atypical cases and subject to medical review. The age groups are standard age groups used in the development of the TRISS analysis. Figure 39. Pediatric Pre Charts include blunt and penetrating mechanisms for patients < 15 years.

Pediatric AIS 2005 Coding Generated 04/11/2018

Arrival Dates 01/01/2017 - 12/31/2017 Query ISS_12_OR_HIGHER

1 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 + +---+----+----+----+----+----+----+----+----+----+----+----+----+----+----+ + | | 0 + D + 0 | | + + | .. | 1 + .... + 1 | ....... | R + ......... + E | ............ | V 2 + .............. + 2 I | ................ | S + ................... + E | ..................... | D 3 + ........................D + 3 | .......................... | T + ............................. + R | ..........................D.... | A 4 + ................................. + 4 U | .................................... | M + ...................................... + A | ......................................... | 5 + ........................................... + 5 S | ............................................. | C + ................................................ + O | .................................................. | R 6 + ..................................................... + 6 E | ....................................................... | + .........................L................................ + | ............................................................ | 7 + ................L...L......................................... + 7 | ................................................................. | + ....................L..L........................................... + | ............LL.LL...L...LL...L........................................ | 8 + +---+----+----+----+----+----+----+----+----+----+----+----+----+----+----+ + 8 1 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 L = SURVIVOR(S) SHADED = Ps >= 0.50 D = DEATH(S) INJURY SEVERITY SCORE B = BOTH

There was one unexpected death for patients less than 15 years using the TRISS methodology. All deaths are reviewed at the Trauma Quality Management Committee to ensure appropriateness of care.


67

Figure 40. Adult Pre Charts include blunt and penetrating mechanisms between 15 and 17 years.

Adult Blunt (15 - 54) AIS 2005 Coding Generated 04/11/2018

Arrival Dates 01/01/2017 - 12/31/2017 Query ISS_12_OR_HIGHER

1 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 + +---+----+----+----+----+----+----+----+----+----+----+----+----+----+----+ + | | 0 + + 0 | | + + | .. | 1 + .... + 1 | ....... | R + ......... + E | ............ | V 2 + .............. + 2 I | ................ | S + ................... + E | ..................... | D 3 + ........................ + 3 | .......................... | T + ............................. + R | ............................... | A 4 + ................................. + 4 U | .................................... | M + ...................................... + A | ......................................... | 5 + ........................................... + 5 S | ............................................. | C + ................................................ + O | .................................................. | R 6 + ..................................................... + 6 E | ....................................................... | + .......................................................... + | ............................................................ | 7 + .............................................................. + 7 | ................................................................. | + ................................................................... + | ...............L........L............................................. | 8 + +---+----+----+----+----+----+----+----+----+----+----+----+----+----+----+ + 8 1 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 L = SURVIVOR(S) SHADED = Ps >= 0.50 D = DEATH(S) INJURY SEVERITY SCORE B = BOTH

There were no unexpected deaths for patients between 15 and 17 years in 2017 using the TRISS methodology.

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