ALBERTA CHILDREN’S HOSPITAL PEDIATRIC TRAUMA … · 2016. 6. 23. · The year 2011-2012 was an...

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ALBERTA CHILDREN’S HOSPITAL

PEDIATRIC TRAUMA PROGRAM

ANNUAL REPORT

2011 – 2012

ACH Trauma Program Staff

Dr. Vincent Grant (until June 30, 2011) ................................... Medical Director

Dr. Angelo Mikrogianakis ................................................. Co - Medical Director

Dr. Mary Brindle ................................................................ Co - Medical Director

Rod Iwanow .............................................................. Trauma Program Manager

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

Jennifer Dueck (until Oct 2011) ..................................................... Data Analyst

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

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TABLE OF CONTENTS

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

2. Clinical Care .................................................................................................. 5

3. Education ...................................................................................................... 7

4. Research ....................................................................................................... 9

5. Quality Assurance ....................................................................................... 11

6. Future Planning .......................................................................................... 12

APPENDICES

Appendix A Trauma Quality Indicators……………………………………….….13

Appendix B Major Trauma Statistics…………………………………….……….29

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1. Introduction The year 2011-2012 was an extremely busy and rewarding year for the Pediatric Trauma Program at the Alberta Children’s Hospital (ACH). As one of the recommendations from the Trauma Association of Canada (TAC) Accreditation in November 2010, the Pediatric Trauma Program became fully independent of the former Regional (Adult) Trauma Services Program in the Calgary Zone of Alberta Health Services. This meant that ACH has now taken full responsibility and accountability for the operations of the program. This is a significant accomplishment and reflects the very hard work of the Trauma Program staff and the Pediatric Trauma Committee. The Pediatric Trauma Program would like to send a special thank you to Regional (Adult) Trauma Services for their support and guidance. Although the TAC Accreditation was a positive endorsement of excellent trauma care at the ACH, it also highlighted several areas that need improvement. We look forward to making those areas high priority items for the Pediatric Trauma Committee in the time ahead. Planning around several of these items is currently underway. They include:

• on-going advocacy for a dedicated Trauma Team Leader service • addition of interventional radiology as a 24/7 service • increased visibility of injury prevention initiatives within the hospital • addition of all trauma patients from 15-17 years of age from our traditional

catchment area 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 TAC. Of note, the current Pediatric Trauma Coordinator, Sherry MacGillivray, is the current co-chair for the Pediatric Committee of TAC. In 2011-2012, the ACH Trauma Program continued 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 trauma codes for the ED and OR, monthly Pediatric Trauma Rounds, twice yearly Trauma Nursing Core Courses (TNCC) and outreach education to Southern Alberta by partnering with KidSIM™, the Pediatric Human Patient Simulation Program at ACH. We would like to thank all of our trauma educators for outstanding teaching throughout the year. The ACH Trauma Program would also like to thank the Alberta Children’s Hospital Foundation, who has continued to support our education initiatives in terms of TNCC and simulation. Our main goals continue to be strong clinical care, excellence and leadership in pediatric trauma education both within the Alberta Children’s Hospital and to our regional partners, on-going advocacy in injury prevention and continued productivity in quality assurance and research.

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We wish to thank all of the staff at the Alberta Children’s Hospital who have had an impact on the Pediatric Trauma Program, and who continue to support our goals in caring for critically injured children and youth. In particular, a great deal of thanks goes to the nurses, physicians, respiratory therapists, and other front-line staff who remain devoted to the care of these children and their families, as well as all of the other staff who make excellence in pediatric trauma care at the Alberta Children’s Hospital a veritable “team effort”. On a final note, June 2011 marked the official end of the five-year term for Dr. Vincent Grant. His leadership and direction for this Program is evident in the status and accreditation it has received. Dr. Grant would like to personally extend his gratitude to all those who made the last five-years possible, including all the members of the Pediatric Trauma Committee and Pediatric Trauma Quality Management Committee who worked very hard to improve the various ways pediatric trauma patients are care for. He was always impressed by how passionately the various committee members wanted to improve care for trauma patients, and their willingness to put occasional differences aside to work together to provide true visionary leadership together. He would also like to thank both Sherry and Jennifer for all of their hard work and dedication to the program. The future of the Trauma Program at ACH is bright and Dr. Grant wishes the team all the best as they chart a new course. Drs. Mary Brindle and Angelo Mikrogianakis replaced Dr. Grant as co-medical directors. The Pediatric Trauma Program would like to acknowledgement their enthusiasm and dedication in taking over this temporary role while a new permanent replacement is sought. Jennifer Dueck also left the role of Data Analyst to pursue her talent in stage acting. The Pediatric Trauma Program would like to extend a sincere thank you for her hard work and dedication to the Program and would also like to congratulate her on her new career. Linda-Mae Grey filled the role with robust enthusiasm that is already visible in her assistance in the following report. 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. Over the past year the following activities have been carried out:

ii) 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. There were no significant changes in 2011-2012.

iii) 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 led by the Division of Pediatric General Surgery. They provide attending physician coverage for this service 24 hours a day, 7 days a week, 365 days a year. There were no significant changes in 2011-2012.

iv) Pediatric Trauma Nurse Practitioner

• This position continues to support both the in-patient trauma service, as well as the medical needs of rehabilitation patients in the hospital and a significant role on the Brain Injury Team. There were no significant changes in 2011-2012.

v) Trauma Team Activation Guidelines (Code 77)

• A complete overhaul of the trauma team activation guidelines was instituted in October 2007. These guidelines are continuously monitored for ‘over’ and ‘under’ triage and for any issues that arise. In January 2012 MVC Rollover mechanism was removed due to a large amount of overtriage. Our goal is to undertriage < 5%. The literature suggests this might mean an overtriage rate up to 50%. The undertriage rate for 2011-2012 was 3% with an overtriage rate of 41%, meaning we are appropriately meeting those targets.

vi) OR Activation (Code 88)

• A code 88 activation is called in order to mobilize both anesthesia and the OR nurses and respiratory therapists 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) and the Pediatric Intensivist. Activations are monitored and reviewed by the Trauma Committee. This past year 2 PACU RN’s were added to this activation so the recovery room was ready for these patients.

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vii) Trauma Team Leader Record (Code 77) • A new clinical documentation tool was created in 2009 for use 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 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 2011-2012 completion rate was 55%.

viii) Pediatric Massive Transfusion Protocol

• The Pediatric Massive Transfusion Protocol was initiated in 2009. Additionally, there are 2 units of O negative pRBCs in the ED trauma room that are for immediate use. In June 2011, in partnership with the ACH Transfusion Medicine, this protocol was expanded to benefit all ACH patients – not just trauma.

ix) Trauma ‘No Refusal’ Policy

• An ACH ‘No Refusal’ Policy for pediatric trauma patients was endorsed by the Pediatric Trauma Committee in 2010-2011. 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 ICU or in-patient beds available. Under those circumstances, patients will be accepted and stabilized in the ED at ACH, while further disposition is arranged.

x) Trauma Beading Program

• Thanks to a generous grant from the Alberta Children’s Hospital Foundation, the Trauma Beading Program for major trauma patients remains an on-going program. 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 Foundation and the ACH Child Life Specialists for making this important program a reality.

xi) Liaising with Regional, Provincial and National Groups

• Provincial Trauma Committee - Members • Interdisciplinary Trauma Network of Canada - Member • Trauma Association of Canada - Members • National Emergency Nurses Association - Member • Canadian Hospitals Injury Prevention & Reporting Prevention Programs

(CHIRPP) - Members

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3. Education

i) Trauma Rounds • April 14, 2011 - Dr. Deepak Kaura “Diagnostic imaging in Non-Accidental

Trauma”

• May 12, 2011 - Dr. Jonathan Guilfoyle “Pediatric Penetrating Trauma”

• June 9, 2011 - Sandra Good “Pediatric Organ Donation”

• October 13, 2011 - Dr. Eli Gilad “Hypothermia, Ice Water Submersion and Avalanche Accidents”

• November 10, 2011 - Detective Doug Hudacin “Street Drugs and Violence in Calgary”

• December 9, 2011 - Dr. Ping Chen “Trauma M & M”

• January 12, 2012 - Linda McCracken “Undetected Trauma and the Role of Universal DV Assessment of Parent of Children”

• February 9, 2012 - Christine O’Leary and Dr. Kerry Carter “Pain Management in the Pediatric Trauma Patient: From Admission to Discharge and Beyond”

• March 8, 2012 - Trudi Canning-Senger “Canadian Hospital Injury Reporting Prevention Program (CHIRPP) 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 been very well received. This course is partially funded by a generous grant from the Alberta Children’s Hospital Foundation.

iii) Mock Trauma Codes Mock trauma codes provided residents, ED physicians, Anesthetists, Surgeons, ED nurses, OR nurses, respiratory therapists, nursing aides and unit clerks with an opportunity to learn from simulated trauma cases.

iv) Outreach Education The partnership that was started in 2007 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 are expected to expand even further in the future.

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The following centres were visited in 2011-2012:

April 2011 – Olds, Medicine Hat, Innisfail May 2011 – Black Diamond June 2011 – Didsbury, Cranbrook BC Sept 2011 – South Calgary Health Centre Oct 2011 – Strathmore, Lethbridge Nov 2011 – Red Deer Jan 2012 – Canmore Feb 2012 – Drumheller March 2012 – High River

v) Emergency Trauma Simulation Sessions

Trauma simulation sessions were held for ED nurses as part of their annual education in conjunction with residents rotating through the Pediatric Emergency Medicine rotation. Human Patient Simulators were used to replicate the assessment and management of trauma patients in real time in an interprofessional environment. These sessions were very well received and will continue in the future.

vi) Nursing Sessions

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

vii) University of Calgary, Undergraduate Medical Education

o Course VI Lecture on the Approach to Pediatric Trauma – Dr. V. Grant

viii) PEACH 2011: Pediatric Emergencies at ACH Conference (Calgary, AB -

March 2011) o Pediatric Trauma track – Dr. V. Grant and Sherry MacGillivray

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4. Research

The following research projects were in progress or completed during 2011-2012:

PUBLICATIONS:

1) Branson LJ, Latter J, Currie G, Nettel-Aguirre A, Embree T, Hagel BE. The effect of surfacing and season on playground injury rates. Accepted: Paediatrics & Child Health

2) Kang J, Hagel BE, Emery CA, Meeuwisse W, Senger T. Assessing the representativeness of Canadian Hospitals Injury Reporting and Prevention Program (CHIRPP) sport and recreational injury data in Calgary, Canada. International Journal of Injury Control and Safety Promotion. Available online: 27 Feb 2012, DOI:10.1080/17457300.2012.656315

3) Blanchard I, Doig CJ, Hagel BE, Anton AR, Zygun DA, Kortbeek JB, Powell DG, Williamson TS, Fick GH, Innes GD. Emergency Medical Services Response Time and Mortality in an Urban Setting. Prehospital Emergency Care 2012;1(Jan/March):1-10. Posted online on 25 Oct 2011: doi: 10.3109/10903127.2011.614046

4) Karkhaneh M, Hagel BE, Couperthwaite A, Saunders D, Voaklander DC, Rowe BH. Emergency department coding of bicycle and pedestrian injuries during the transition from ICD-9 to ICD-10. Injury Prevention 2012 Apr;18(2):88-93. Epub 2011 Jun 24.

5) Emery CA, Kang J, Goulet C, Shrier I, Hagel BE, Benson B, Nettel-Aguirre A, Hamilton G, Meeuwisse WH. The risk of injury associated with body checking experience in youth ice hockey players. Canadian Medical Association Journal 2011;183:1249-1256. Published online ahead of print June 20, 2011. DOI:10.1503/cmaj.101540

6) Mikrogianakis A, Kam A, Silver S, Bakanisi B, Henao O, Okrainec A, Azzie G: Telesimulation: An Innovative and Effective Tool for Teaching Novel Intraosseous Insertion Techniques in Developing Countries: 2011 by the Society for Academic Emergency Medicine DOI: 10.1111/j.1553-2712.2011.01038x

7) Chung S, Mikrogianakis A, Wales P, Dirks P, Shroff M, Singhal A, Grant VJ,

Hancock BJ, Creery D, Atkingson J, St-Vil D, Crevier L, Yanchar N, Hayashi A, Mehta V, Carey T, Dhanani S, Siemens R, Singh S, Price D: Trauma Association of Canada Pediatric Subcommittee National Pediatric Cervical Spine Evaluation Pathway: Consensus Guidelines: The Journal of Trauma Injury, Infection, and Critical Care: Volume 70, Number 4, April 2011

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IN PROGRESS:

1) Karkhaneh M, Rowe BH, Voaklander D, Saunders D, Hagel BE. The effect of bike helmet legislation on helmet use, head injuries and cycling habits.

2) Hagel BE, Rowe BH, Voaklander D, Kyle T. Does visibility influence the risk of injury in cyclists?

3) Russell K, Meeuwisse W, Emery CA, Nettel-Aguirre A, Hagel BE. The

relationship between injuries and terrain park equipment use among pediatric and adult snowboarders in Alberta

4) McCrossin C, Grant VJ. Incidence of intra-abdominal injuries identified by CT

scanning in cases of blunt pediatric trauma: A retrospective chart review.

5) Brindle ME, Beres AL, Wales PW, Christison-Lagay ER, McClure E, Fallat E. Nonoperative management of high grade pancreatic trauma: Is it worth the wait?

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5. Quality Assurance As part of the Regional Trauma Services 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. No changes were made this past year. ACH performance indicators for 2011-2012 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 2012-2013 year will focus on the following activities: • Searching for a new permanent medical director • Obtaining dedicated funding for a formal Trauma Team Leader program • Continuing to collect data in terms of the care and needs of 15-17 year old trauma

patients and the impact on current operations, human resources and equipment with the goal of eventual repatriation

• 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 • Focusing on improving 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

ACH Trauma Quality Indicators (ISS>12) 2011/2012

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Appendix A Alberta Children’s Hospital Trauma Quality Indicators for 2011/2012 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).

Indicator Yes No

2011/2012, n = 77 71 6 2010/2011, n = 66 61 5 2009/2010, n = 69 65 4 2008/2009, n = 64 54 10 2007/2008, n = 80 71 9

Pre-hospital documentation is sometimes difficult to obtain especially for those from out of Province. Cooperation with Alberta Health Services EMS since Nov 2011 now allows on-line record access which should improve the compliance of this indicator. 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.

Indicator Yes No

2011/2012, n = 11 2 9 2010/2011, n = 6 3 3 2009/2010, n = 5 2 3 2008/2009, n = 11 3 8 2007/2008, n = 17 8 9

89

84

94

92 92

11 16

6 8 8

2007/2008 2008/2009 2009/2010 2010/2011 2011/2012

%Yes %No

47 27 40 50

18

53 73 60 50

82

2007/2008 2008/2009 2009/2010 2010/2011 2011/2012

%Yes %No


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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. These patients are reviewed at the Pediatric Trauma Quality Management Committee to ensure appropriate care was given. 3. Length of stay 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.

Indicator Yes No

2011/2012, n = 33 20 13

2010/2011, n = 35 24 11

2009/2010, n = 25 16 9

2008/2009, n = 29 21 8

2007/2008, n = 28 17 11

If at any time the ACH Pediatric Trauma Quality Management Committee feels that the Rural Hospital LOS is not acceptable, a letter 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 a Provincial Trauma Committee 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 or Stollery Hospitals in Edmonton, Red Deer, Lethbridge or Medicine Hat Hospitals. Exclusions: Out of the 40 patient transfers, 6 patients were transferred from within Calgary, 6 from Lethbridge, 4 from Red Deer and 2 from Medicine Hat resulting in a total (n) of 22 patients for this indicator. Inclusions: n = all patients transferred from a non-trauma centre hospital with a known time of injury and known time of arrival.

Indicator Yes No 2011/2012, n = 22 9 13

2010/2011, n = 22 5 17

2009/2010, n = 18 4 14

2008/2009, n = 13 1 12

2007/2008, n = 28 11 17

61 72 64 69 61

39 28 36 31 39

2007/2008 2008/2009 2009/2010 2010/2011 2011/2012

%Yes %No

39

8 22 23 41

61 92

78 77 59

2007/2008 2008/2009 2009/2010 2010/2011 2011/2012

%Yes %No


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A high number of patients were not seen at a Trauma Centre within the 4 hour timeline. Although many factors contribute to delays, most are found to be related to challenges in mobilizing transfer of patients from rural health centers. Again, the Provincial Trauma Committee is making this trend a priority to resolve through revisions of pre-hospital transport algorithms and guidelines. 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.

Indicator Yes No 2011/2012, n = 42 9 33

2010/2011, n = 40 13 27

2009/2010, n = 31 5 26

2008/2009, n = 33 6 27

2007/2008, n = 35 4 31

The Alberta Children’s Hospital offers a specialized Pediatric Transport Team Service, which transports critically ill or injured children from referring 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 Link Center communications, 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 call for difficult cases. This Service has gone through recent changes which have increased the efficiency of mobilization, thereby making it a more feasible alternative for the transport of acutely injured children.

11 18 16 33

21

86 82 84 68 79

2007/2008 2008/2009 2009/2010 2010/2011 2011/2012

%Yes %No


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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 some cases, the trauma team may be called however the patient does not meet the Trauma Registry inclusion criteria. This past year the increase in activations can be attributed to the ED nurses’ compliance with the criteria. 7. Direct Admission - Bypassed the Emergency Department (ED)

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

Indicator Yes No 2011/2012, n = 89 7 82 2010/2011, n = 82 11 71 2009/2010, n = 82 8 74 2008/2009, n = 74 15 59 2007/2008, n = 97 8 89

There is currently a No Direct Admit Policy for trauma patients. However if the injury is more than 24 hours old this policy does not apply. This past year, 2 of the 7 patients were directly admitted to the PICU and Unit 2 with injuries older than 24 hours. One was sent directly to the PICU from the FMC once the age was determined. One was admitted directly to Unit 4 (trauma unit) with no initial history of trauma. The remaining 3 patients were discussed at the Pediatric Trauma Quality Management Committee and care was deemed appropriate.

8 20 10 13 8

92 80 90 87 92

2007/2008 2008/2009 2009/2010 2010/2011 2011/2012

%Yes %No

2 1

6

1

5

3 2 2 2

0 0

3

1

4

2

5 5

2 1

3

0

3

1

3 3 2

4

2

4 5

3

1 1 1

3 2

8

5

7

9 10

8

10

6 7

4

9

7

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

# of

Act

ivat

ions

Major Trauma Team Activation 2008/2009 to 2011/2012

2008/2009 2009/2010 2010/2011 2011/2012


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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.

Indicator Yes No

2011/2012, n = 0 0 0

2010/2011, n = 2 2 0

2009/2010, n = 4 3 1

2008/2009, n = 5 5 0

2007/2008, n = 9 9 0

This past year there were no patients that arrived at ACH ED with the first recorded GCS < 8 that were not already intubated pre-arrival either in the field or at a rural hospital. There were 5 patients that had a first recorded GCS < 8 with EMS but then improved upon arrival to ACH. 9. Presence of ED nursing documentation every 30 minutes.

After arrival at the trauma centre, was q 30 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.

Indicator Yes No

2011/2012, n = 83 30 53

2010/2011, n = 71 25 46

2009/2010, n = 75 31 44

2008/2009, n = 59 28 31

2007/2008, n = 89 60 29

ED documentation continues to be an indicator that is flagged often but is considered to be important for patient care. ED education is done in a variety of ways to encourage this 30 minute frequency, which is different from the usual ED documentation of hourly.

100 100 75

100

0

0 0 25

0

0 2007/2008 2008/2009 2009/2010 2010/2011 2011/2012

%Yes %No

67 47 42

35 37

33 53 58 65 63

2007/2008 2008/2009 2009/2010 2010/2011 2011/2012

%Yes %No


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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

Indicator Yes No

2011/2012, n = 65 47 18

2010/2011, n = 64 44 20

2009/2010, n = 62 38 24

2008/2009, n = 52 36 16

2007/2008, n = 70 48 22

Trauma Packs which include a separate Neurological Vital Sign sheet are in the ACH ED Trauma Room to remind nurses to trend this important vital sign. 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.

Indicator Yes No

2011/2012, n = 79 1 78

2010/2011, n = 72 2 70

2009/2010, n = 72 1 71

2008/2009, n = 57 2 55

2007/2008, n = 83 1 82

This hypothermic patient was reviewed by the Trauma Quality Management Committee where recommendations were made but care was deemed appropriate.

69 69 61 69 72

31 30 39 31 28

2007/2008 2008/2009 2009/2010 2010/2011 2011/2012

%Yes %No

2 4 1 3 1

98 97 99 97 99

2007/2008 2008/2009 2009/2010 2010/2011 2011/2012

%Yes %No


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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.

Indicator Yes No

2011/2012, n = 14 13 1

2010/2011, n = 11 11 0

2009/2010, n = 12 12 0

2008/2009, n = 11 11 0

2007/2008, n = 10 10 0

This patient presented with a GCS < 12 due to non head injury reasons therefore a CT head was not deemed necessary as per review at the Pediatric Trauma Quality Management Committee. 13. Patient stay in ED less than 4 hours.

Did the patient have an ACH ED length of stay < 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.

Indicator Yes No

2011/2012, n = 81 40 41

2010/2011, n = 72 35 37

2009/2010, n = 75 39 36

2008/2009, n = 59 27 32

2007/2008, n = 89 56 33

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 resolved.

100 100 100 100

93

0 0 0 0

7

2007/2008 2008/2009 2009/2010 2010/2011 2011/2012

%Yes %No

63 46

52 49 49

37 54 48 51 51

2007/2008 2008/2009 2009/2010 2010/2011 2011/2012

%Yes %No


20

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.

Indicator Yes No

2011/2012, n = 89 82 7

2010/2011, n = 82 76 6

2009/2010, n = 83 77 6

2008/2009, n = 74 67 7

2007/2008, n = 89 79 10

Out of the 7 patients that were initially admitted to a non-surgeon or an intensivist, all were deemed appropriate according to admission guidelines. All were admitted to the Pediatrics Service: 4 were admitted for work up of non-accidental injuries, 2 were isolated head injuries less than one year of age and one had burns with Plastic surgery following. 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.

Indicator Yes No

2011/2012, n = 3 3 0

2010/2011, n = 4 4 0

2009/2010, n = 6 6 0

2008/2009, n = 3 3 0

2007/2008, n = 3 3 0

89 91 93 93 92

11 10 7 7 8

2007/2008 2008/2009 2009/2010 2010/2011 2011/2012

%Yes %No

100 100 100 100 100

0 0 0 0 0

2007/2008 2008/2009 2009/2010 2010/2011 2011/2012

%Yes %No

0


21

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.

Indicator Yes No

2011/2012, n = 89 0 89

2010/2011, n = 82 0 82

2009/2010, n = 83 0 83

2008/2009, n = 74 0 74

2007/2008, n = 94 0 94

17. Any laparotomy procedure performed.

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

Indicator Yes No

2011/2012, n = 90 4 86

2010/2011, n = 83 4 79

2009/2010, n = 83 4 79

2008/2009, n = 74 3 71

2007/2008, n = 97 4 93

The small number of laparotomies performed this past year remains consistent with historical trends and continues to show the conservative management philosophy in pediatrics in regards to abdominal trauma.

100 100 100 100 100

2007/2008 2008/2009 2009/2010 2010/2011 2011/2012

%Yes %No

5 4 5 5 4

96 96 95 95 96

2007/2008 2008/2009 2009/2010 2010/2011 2011/2012

%Yes %No


22

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.

Indicator Yes No

2011/2012, n = 7 6 1

2010/2011, n = 4 3 1

2009/2010, n = 6 6 0

2008/2009, n = 3 3 0

2007/2008, n= 4 2 2

This year one patient had operative management just outside the 24 hours due to instability from an airway perspective. Buck’s traction was used appropriately until OR was done. Care was deemed appropriate as per the Trauma Quality Management Committee review. 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.

Indicator Yes No

2011/2012, n = 2 1 1

2010/2011, n = 1 1 0

2009/2010, n = 0 0 0

2008/2009, n = 0 0 0

2007/2008, n = 1 1 0

This year one patient was taken to the OR quickly for irrigation and debridement of an open # and then returned to the OR the next day for management of the fracture. Care was deemed appropriate as per the Trauma Quality Management Committee review.

50

100 100 75 86

50

0 0 25

2007/2008 2008/2009 2009/2010 2010/2011 2011/2012

%Yes %No

14

0 0 50 0 0

50

2007/2008 2008/2009 2009/2010 2010/2011 2011/2012

%Yes %No


23

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.

Indicator Yes No

2011/2012, n = 30 0 30

2010/2011, n = 34 0 34

2009/2010, n = 43 2 41

2008/2009, n = 26 0 26

2007/2008, n = 27 1 26

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.

Indicator Yes No

2011/2012, n = 89 0 89

2010/2011, n = 82 0 82

2009/2010, n = 82 1 81

2008/2009, n = 74 0 74

2007/2008, n = 94 0 94

A trauma tertiary survey performed by the Trauma Surgery NP, Fellow or Resident at 24 hours after admission to the trauma centre helps to keep missed injuries to a minimum.

4 0 5 0 0

96 100 95 100 100

2007/2008 2008/2009 2009/2010 2010/2011 2011/2012

%Yes %No

0 0 1 0 0

100 100 99 100 100

2007/2008 2008/2009 2009/2010 2010/2011 2011/2012

%Yes %No


24

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.

Indicator Yes No

2011/2012, n = 3 2 1

2010/2011, n = 0 0 0

2009/2010, n = 2 2 0

2008/2009, n = 0 0 0

2007/2008, n = 0 0 0

The patient mentioned above in indicator 19 did not have her joint dislocation reduced until deemed appropriate by the Orthopedic Surgeon. Care was deemed appropriate as per the Trauma Quality Management Committee review. 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.

Indicator Yes No

2011/2012, n = 0 0 0

2010/2011, n = 0 0 0

2009/2010, n = 0 0 0

2008/2009, n = 0 0 0

2007/2008, n = 0 0 0

0 0

100

0

67

2007/2008 2008/2009 2009/2010 2010/2011 2011/2012

%Yes %No

33

0 0 0 0 0

2007/2008 2008/2009 2009/2010 2010/2011 2011/2012

%Yes %No


25

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.

Indicator Yes No

2011/2012, n = 1 0 1

2010/2011, n = 1 1 0

2009/2010, n = 2 2 0

2008/2009, n = 2 2 0

2007/2008, n = 2 2 0

The one patient this year was too unstable to take to the OR for facial fracture fixation within 7 days. Care was deemed appropriate as per the Trauma Quality Management Committee review. 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.

Indicator Yes No

2011/2012, n = 0 0 0

2010/2011, n = 1 1 0

2009/2010, n = 0 0 0 2008/2009, n = 0 0 0

2007/2008, n = 0 0 0

100 100 100 100

0

0 0

2007/2008 2008/2009 2009/2010 2010/2011 2011/2012

%Yes %No

100

0 0 0

100

0

2007/2008 2008/2009 2009/2010 2010/2011 2011/2012

%Yes %No


26

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.

Indicator Yes No

2011/2012 n = 0 0 0

2010/2011, n = 0 0 0

2009/2010, n = 2 0 2

2008/2009, n = 0 0 0

2007/2008, n = 0 0 0

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.

Indicator Yes No

2011/2012 n = 1 0 1

2010/2011, n = 0 0 0

2009/2010, n = 1 1 0

2008/2009, n = 0 0 0

2007/2008, n = 0 0 0

0 0 0 0

100

2007/2008 2008/2009 2009/2010 2010/2011 2011/2012

%Yes %No

0 0

100

0 0 0 0

0

0

100

2007/2008 2008/2009 2009/2010 2010/2011 2011/2012

%Yes %No


27

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.

Indicator Yes No

2011/2012, n = 89 1 88

2010/2011, n = 82 2 80

2009/2010, n = 82 0 82

2008/2009, n = 74 0 74

2007/2008, n = 89 0 89

This year one patient needed to be transferred to the PICU from the trauma unit due to instability. The PICU Specialized Transitional Educational Personnel (STEP) team was initiated in November 2011 which aided in these types of quick assessments and transfers.

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.

Indicator Yes No

2011/2012, n = 36 3 33

2010/2011, n = 36 1 35

2009/2010, n = 36 0 36

2008/2009, n = 31 1 30

2007/2008, n = 49 0 49

These three patients needed re-admission to the PICU due to instability. As mentioned above, the outreach PICU STEP team has been developed to aid in these types of patients and subsequent transfers to PICU.

0 0 0 2 1

100 100 100 98 99

2007/2008 2008/2009 2009/2010 2010/2011 2011/2012

%Yes %No

0 3 0 3 0

100 97 100 97 100

2007/2008 2008/2009 2009/2010 2010/2011 2011/2012

%Yes %No


28

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.

Indicator Yes No

2011/2012, n = 4 3 1

2010/2011, n = 5 3 2

2009/2010, n = 8 4 4

2008/2009, n = 2 1 1

2007/2008, n = 15 10 5

Unfortunately 3 patients died in the first 24 hours of admission to ACH in 2011/2012. All death cases were reviewed by the Pediatric Trauma Quality Management Committee and care was deemed appropriate. 30. Did the patient die in ACH?

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

Indicator Yes No

2011/2012, n = 90 4 86

2010/2011, n = 83 5 78

2009/2010, n = 83 8 75

2008/2009, n = 74 2 72

2007/2008, n = 97 13 84

One additional patient died after 24 hours this past year which was also reviewed at the Pediatric Trauma Quality Management Committee and care was deemed appropriate.

67 50 50 60 75

33 50 50 40 25

2007/2008 2008/2009 2009/2010 2010/2011 2011/2012

%Yes %No

13 3 10 6 4

87 97 90 94 96

2007/2008 2008/2009 2009/2010 2010/2011 2011/2012

%Yes %No

ACH Major Trauma Statistics (ISS>12) 2011/2012

29

APPENDIX B Major Trauma Statistics for 2011/2012

1. General Overview Age Gender

2. Etiology of Injuries Mechanism of Injury Type of Injury Place of Injury 3. Referrals Referrals from Health Regions Mode of Transportation to ACH Ground vs Air Transport ED Arrival By Month, Day and Time of Arrival Disposition from the Emergency Department

4. Patient Care Management Diagnostic Imaging Statistics Day of Week and Time of CT Non-Operative Procedures Performed in ED Surgical Procedures OR Data by Service Time to OR Length of Stay Admitting Physician Service Hospital Discharge Destination Outcomes by Age and ISS TRISS Pre-Charts


30

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

2007/2008 2008/2009 2009/2010 2010/2011 2011/2012 Total Patients

97 74 83 83 90

Males

54 55.7%

49 66.2%

55 66.3%

53 63.9%

57 63.3%

Females

43 44.3%

25 33.8%

28 33.7%

30 36.1%

33 36.7%

Total Length of Stay (LOS) (days)

943 1052 956 1046 812

Median LOS

5 5 4 6 5

Mean LOS

11 14 12 13 9

Total Emergency Department (ED) LOS (hours)

345.8 277.1 328.4 328.8 397.6

Median ED LOS (hours)

3.4 4.1 3.7 4.0 3.4

Mean ED LOS (hours)

3.9 4.7 4.4 4.6 4.9

ICU Admissions

49 50.5%

29 39.2%

36 43.4%

36 43.4%

37 41.1%

Median ICU LOS (days)

2 4 2 2 1

Mean ICU LOS (days)

4 6.7 10 4 4

Total ICU LOS (days)

198 193 352 160 163

Median ISS

24 20 17 17 16

Mean ISS

23.9 22.8 20 21 21

Direct Admits

8 15 8 11 7

Referrals to ACH from other centres

35 36.1%

33 44.6%

29 34.9%

35 42.2%

40 44.4%

Deaths 13 13.4%

2 2.7%

8 9.7%

5 6%

4 4.4%

In 2011/2012, 90 major trauma patients (meeting criteria for inclusion in the trauma registry) were

seen at the ACH. This volume is slightly higher than the five-year average of 85 major trauma patients seen annually. This 2011/2012 trauma volume represents 10.0% of all patients admitted to the ACH with injuries (n=899), which is a 0.2% increase from last year. As seen in previous years, the percentage of major trauma patients who are males (63.3%) continues to be greater than females, which is consistent with the five-year average of 63%. Major trauma patients referred in from other centers represented


31

44.4% of the major trauma volume for 2011/2012. This is slightly higher than the five-year average of 40%.

Length of stay for major trauma patients ranged between 1 and 49 days. Mean LOS of 9 days is lower than the five-year trend of 11.8. Median LOS of 5 days is consistent with the five-year trend of 5.

The total ED LOS was 397.6 hours, and higher than the five-year average of 336 hours. Both the mean and median LOS were consistent with the five-year averages of 4.5 and 3.7 respectively.

In 2011/2012, 41.1% of major trauma patients were admitted to the ICU, which is slightly lower than the five-year average of 43.5%. Total ICU LOS was 163 days, which is lower than the five-year average of 213. The mean ICU LOS is lower than the five-year average of 5.7 and the median is consistent at 1.

Both the mean (21) and median (16) ISS for major trauma patient from 2011/2012 were slightly lower than the five-year averages of 21.7 (mean) and 18.8 (median).

A total of 4 deaths were seen in major trauma patients in 2011/2012. This represents 4% of major trauma volume, and is lower than the five-year average of 7.2%.


32

Figure 1. Age and Gender Distribution for ACH Major Trauma Patients for 2011/2012

Figure 1 shows the number of males and females for the above age groups. On average, males comprise 63% of the major trauma population over a period of five years.

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

Figure 2 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 trauma patients 15-17 years of age should normally be transported to the Foothills Medical Centre (FMC). The Pediatric Trauma Program Expansion Proposal contains steps to eventually assume primary trauma care for trauma patients 15-17 years of age. The graph above displays that approximately 1/3 to 1/2 of this group is already cared for at the ACH, mainly due to cases where patient’s ages are unknown at the time of transport, when the FMC is at capacity or when patients present themselves to ACH.

7

11 9

25

5 6

11

7 6 3

0

5

10

15

20

25

30

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

# of

Pat

ient

s

Age Groups

Male Female

2007/2008 2008/2009 2009/2010 2010/2011 2011/2012

ACH 19 11 10 7 8

FMC 37 31 29 24 27

PLC 0 0 0 0 0

RGH 0 0 0 0 0

0

5

10

15

20

25

30

35

40

# of

Pat

ient

s

15 to 17 year olds Major Trauma Patients


33

2. Etiology of Injuries

Mechanism of Injury describes the nature of the injury, such as 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 2011/2012 as compared to the historical trend. This past year was fairly consistent with the past few years

Transport 41%

Falls 27%

Violence 6%

Other 26%

2007/2008 - 2011/2012

Transport 39%

Falls 30%

Violence 8%

Other 23%

2011/2012

Transport 41%

Falls 27%

Violence 6%

Other 26%

2007/2008 - 2011/2012


34

Mechanism of Injury – Transportation Figure 4. Transportation Statistics

Figure 4 shows the breakdown of transportation-related injuries in 2011/2012 as compared to the historical trend. There was a decrease in MVC injuries this past year. A total of 35 patients (39% of major trauma patients) were involved in transportation-related incidents in 2011/2012.

Mortality: 0%: All patients survived. ISS ranged from 13 to 48. Mean ISS was 23 and median ISS was 17.

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

Figure 5 shows the 10% increase in transportation-related incidents from 2010/2011 to 2011/2012. Note the significant decrease over the past five years – this may be attributed to Injury Prevention campaigns geared towards car seats and booster seats.

54% 45%

34% 29%

39%

0%

10%

20%

30%

40%

50%

60%

2007/2008 2008/2009 2009/2010 2010/2011 2011/2012

% o

f Pat

ient

s

Years

MOI -Transportation

MVC 37%

Pedestrian 26%

Cyclist 23%

MRV 14%

Water 0%

Railway 0%

2011/2012

MVC 45%

Pedestrian 21%

Cyclist 22%

MRV 12%

Water 0%

Railway 0%

2007/2008 - 2010/2011


35

Figure 6. Transportation by Age Group

Figure 6 shows the breakdown of transportation incidents by age groups in 2011/2012 as compared to the historical trend. Significant changes to all age groups can be seen.

In 2011/2012: Age Group <1 (n=1, 3%) included 1 passenger. Age Group 1-4 (n=4, 11%) included 1 pedestrian and 3 passengers. Age Group 5-9 (n=7, 20%) included 3 passengers, 3 bicyclists and 1 ATV related injury. Age Group 10-14 (n=18, 51%) included 6 passengers, 6 pedestrians and 4 bicyclists and 2 ATV

related injuries. Age Group > 14 (n=5, 14%) included 2 passengers, 1 pedestrian and 2 bicyclists.

<1 3%

1 to 4 11%

5 to 9 20%

10 to 14 52%

>14 14%

2011/2012

<1 13%

1 to 4 4%

5 to 9 46%

10 to 14 33%

>14 4%

2007/2008 - 2010/2011


36

Mechanism of Injury – Falls Figure 7. Statistics for Falls as the MOI Figure 7 shows the breakdown of falls incidents in 2011/2012 as compared to the historical trend. This past year saw an increase in multi-level falls as there were a number of children that fell out of upper floor windows – a media campaign was done by the ACH Trauma Program in partnership with Calgary EMS in August 2011.

A total of 27 patients (30% of major trauma patients) were admitted for fall-related injuries.

Mortality: 0%: All patients survived. ISS ranged from 14 to 29. Mean ISS was 18 and the median ISS was 16.

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 is above the five year average of 28%.

22% 26%

29% 33%

30%

0%

5%

10%

15%

20%

25%

30%

35%

2007/2008 2008/2009 2009/2010 2010/2011 2011/2012

% o

f Pat

ient

s

MOI Falls

Multi-Level 59%

Same-Level 15%

Other & Unspecified

26%

2011/2012

Multi-Level 53%

Same-Level 16%

Other & Unspecified

31%

2007/2008 -2010-2011


37

Figure 9. Falls by Age Group

Figure 9 shows the breakdown of fall incidents by age groups in 2011/2012 as compared to the historical trend. A significant increase seen in the 1-4 yr old age group is due to the increased number of upper level window falls – see comment above.

In 2011/2012: Age Group <1 (n=6, 22%) included 4 multi-level falls, 1 same-level fall, and 1 fall on or from

stairs/steps. Age Group 1-4 (n=10, 37%) included 8 multi-level falls, 1 fall on or from stairs/steps and 1 fall from

collision/pushing/shoving. Age Group 5-9 (n=3, 11%) included 1 multi-level falls, 1 same level fall and 1 other/unspecified fall. Age Group 10-14 (n=7, 26%) included 3 multi-level falls, 1 same level fall, 1 fall from

ladders/scaffolding, 1 fall from building and 1 other/unspecified fall. Age Group >14 (n=1, 3%) included 1 same level fall.

<1 22%

1 to 4 37%

5 to 9 11%

10 to 14 26%

>14 4%

2011/2012

<1 28%

1 to 4 20%

5 to 9 18%

10 to 14 29%

>14 5%

2007/2008 - 2010/2011


38

Mechanism of Injury – Violence Figure 10. Violence as the MOI Figure 10 shows the breakdown of violence-related incidents in 2011/2012 as compared to the historical trend. Note that all were from unarmed assaults with the majority caused by non-accidental trauma.

A total of 7 patients (8% of major trauma patients) were admitted for violence-related injuries.

Mortality: 14% (n=1) did not survive. ISS ranged from 14 to 38. The mean ISS for survivors was 26, and for non-survivors 38. The median ISS for survivors was

24 and for non-survivors the median ISS was 38. Figure 11. Five-Year Trend for Violence as the MOI Figure 11 shows the rise of violence related injuries since 2007/2008 with a large spike in 2009/2010. This was due to a large increase in non-accidental trauma cases which have been less this past year. However the overall increase continues to be discussed extensively with the Injury Prevention Program.

Unarmed Assault 100%

2011/2012

Unarmed Assault

69% Other & Unspecifed

3%

Self-Inflicted

17%

Assault with

Object 11%

2007/2008 - 2010/2011

4%

11%

16%

12%

8%

0%

5%

10%

15%

20%

2007/2008 2008/2009 2009/2010 2010/2011 2011/2012

% o

f Pat

ient

s

MOI - Violence


39

Figure 12. Violence Incidents by Age Group

Figure 12 shows the breakdown of violence incidents by age groups in 2011/2012 as compared to the historical trend. Note the large increase of 5-9 yr olds as well as the > 14 yr olds.

Age Group <1 (n=2, 29 %) included two non-accidental/child abuse cases. Age Group 1-4 (n=2, 29%) included two non-accidental/child abuse cases. Age Group 5-9 (n=1, 14%) included one non-accidental/child abuse case that resulted in death. Age Group 10-14 (n=1, 14%) included one non-accidental/child abuse case. Age Group >14 (n=1, 14%) included one assault case.

<1 29%

1 to 4 29%

5 to 9 14%

10 to 14 14%

>14 14%

2011/2012

<1 34%

1 to 4 31% 5 to 9

3%

10 to 14 23%

>14 9%

2007/2008 - 2010/2011


40

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

Figure 13 shows the breakdown of other mechanism of injuries in 2011/2012 as compared to the historical trend. Fire & explosion and inhalation & ingestion injuries were increased this year and note the decrease in animal related injuries. A total of 21 patients (23% of major trauma patients) were admitted for other mechanism of injuries.

Mortality: 14% (n=3) did not survive. ISS ranged from 13 to 32. For survivors, the mean ISS was 18 and the median ISS was 16. For non-survivors, the mean ISS was 26 and median ISS was 25.

Animal 5%

Mechanical 57%

Submersion & Drowning

9%

Inhalation & Ingestion

5%

Fire & Explosion

24%

Other & Unspecified

0%

2011/2012

Animal 20%

Mechanical 61%

Submersion & Drowning

14%

Inhalation & Ingestion

2%

Fire & Explosion

3%

Other & Unspecified

0%

2007/2008 -2010/2011


41

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

Figure 14 shows an overall consistency in the number of patients whose injuries are caused by animal, burn, inhalation, submersion injury, and mechanical-related incidents when compared to the last five years. Figure 15. Other Mechanism by Age Group

Figure 15 shows the breakdown of incidents involving other mechanism of injury by age groups in 2011/2012 as compared to the historical trend. There was an increase in <1 yr olds and 5-9 yr olds. In 2011/2012: Age Group <1 (n=4, 19%) included 1 struck by falling object, 2 mechanical-related mechanisms and 1

severe dog bite resulting in death. Age Group 1-4 (n=6, 28%) included 3 burn injuries, 1 foreign body ingestion and 2 drowning injuries

which both resulted in death. Age Group 5-9 (n=5, 24%) included 2 sports related injuries, 1 striking against object injury, 1 struck

by falling object and 1 burn injury. Age Group 10-14 (n=5, 24%) included 5 sports related injuries. Age Group >14 (n=1, 5%) included 1 burn injury.

<1 19%

1 to 4 28% 5 to 9

24%

10 to 14 24%

>14 5%

2011/2012

<1 9%

1 to 4 24%

5 to 9 14%

10 to 14 35%

>14 18%

2007/2008 - 2010/2011

24%

20% 22%

28%

23%

0%

5%

10%

15%

20%

25%

30%

2007/2008 2008/2009 2009/2010 2010/2011 2011/2012

% o

f Pat

ient

s

MOI - Other


42

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 2011/2012. Blunt injuries comprised 90% of major trauma population. This has been consistent over the past 5 years as seen in figure 17 below. Figure 17. Five-Year Trend for Type of Injury

Figure 17 compares the different types of injuries from 2007/2008 up to 2011/2012. Note the increase in burn injuries this past year.

81

2 5 2 0

50

100

Blunt Penetrating Burn Other

Type of Injury - 2011/2012 Total Pts = 90

84 69

77 75 81

1 1 2 4 2 1 4 2 1 5 11 0 2 3 2

0

20

40

60

80

100

2007/2008 2008/2009 2009/2010 2010/2011 2011/2012

# of

Pat

ient

s

Fiscal Years

Type of Injury - Five Year Trend Total Pts = 427

Blunt Penetrating Burn Other


43

Place of Injury Figure 18. Statistics for Place of Injury

Figure 18 shows where the patients were injured in 2011/2012 as compared to the historical trend. Notable increase occurred to those injured in a street in 2011/2012.

Farm 3%

Home/Res Inst 26%

Other 3%

Public Building

3%

Recreation 17%

Street 36%

Unspecified 12%

2011/2012

Farm 6%

Home/Res Inst 27%

Other 5%

Public Building

4%

Recreation 17%

Street 28%

Unspecified 13%

2007/2008 - 2010/2011


44

3. Referrals to ACH Referral Patterns

Out of 427 major trauma patients from 2007/2008 to 2011/2012, a total of 174 patients (41%) were referred to ACH by other hospitals.

The highest number of out of region referrals to ACH was made by Red Deer Regional Hospital and Lethbridge Regional Hospital with a total of 37 patients (21% of total referrals) over five years. Note the significant increase in referral patients this past year from Banff.

Please 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 2007/2008 2008/2009 2009/2010 2010/2011 2011/2012 Total Region 1 - Chinook Health Region, Total = 36 Blairmore - Crowsnest Pass 1 1 Cardston – Municipal 1 1 1 2 5 Lethbridge Regional 4 4 1 7 6 22 Milk River 1 1 Picture Butte Municipal 1 1 Pincher Creek Municipal 3 1 1 5 Taber H.C.C. 1 1 Region 2 - Palliser Health Region, Total = 18 Bassano General 1 1 2 Bow Island General 1 1 Brooks Health Centre 1 1 2 Medicine Hat Regional 1 3 3 3 2 12 Oyen - Big Country 1 1 Region 3 - Calgary Health Region, Total = 54 Banff - Mineral Springs 1 1 1 1 4 8 Calgary – Foothills 1 8 4 1 2 16 Calgary - General/Peter Lougheed 3 2 2 3 2 12 Calgary – Rockyview General 2 2 Canmore General 2 2 Claresholm General 1 1 2 Didsbury - Mountain View H.C. 1 1 2 High River General 1 1 2 4 Strathmore - Valley General 1 1 1 3 Vulcan General 2 1 3


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Region 4 - David Thompson Health Region, Total = 33 Drumheller Regional 2 1 3 Innisfail H.C.C. 1 1 Red Deer Regional 1 3 5 2 4 15 Olds General 1 1 2 Sundre General 4 1 1 6 Stettler General 2 2 Three Hills H.C.C. 2 1 3 Rocky Mountain House 1 1 Other Alberta Hospitals, Total = 3 University of Alberta Hospital 1 1 1 3 British Columbia, Total = 22 Cranbrook Regional Hospital 2 2 3 1 8 Fernie District Hospital 1 1 Golden & District General Hospital 2 2 1 5 Invermere District Hospital 2 2 1 1 6 Salmon Arm, Shuswap Hospital 1 1 Sparwood General Hospital 1 1 Nova Scotia, Total = 1 Cape Breton 1 1 Saskatchewan, Total = 5 Lloydminster General 1 2 3 Maidstone Union Hospital 1 1 Royal University Hospital, Saskatoon 1 1 Out of Country, Total = 2 Montana 1 1 Egypt 1 1


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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 2011/2012 as compared to the historical trend. Note the decrease 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 2011/2012 as compared to the historical trend. Means of transport is part of the review process with each major trauma patient to ensure the patient comes to ACH the safest way possible.

Ground 66%

Helicopter 2%

Fixed-wing 0%

Private/ Walk-in

32%

2011/2012

Ground 62%

Helicopter 9%

Fixed-wing 0%

Private/ Walk-in

29%

2007/2008 - 2010/2011

Ground 65%

Helicopter 22%

Fixed-wing 10%

Private vehicle

3%

2011/2012

Ground 61%

Helicopter 21%

Fixed-wing 15%

Private vehicle

3%

2007/2008 - 2010/2011


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Figure 21. Ground vs Air

Ground ambulance transported 59 patients (66%) of major trauma patients in 2011/2012, which is slightly higher than the previous fiscal year. Their ISS was a mean of 22 and median of 17. Figure 21 also shows the decrease in the use of air transport by 1% in 2011/2012. Patients transported by air had an ISS mean of 23 and median of 22. Month and Time of Arrival Figure 22. Month of Arrival

There was an increase in major trauma patients arriving in ACH ED in April, October, December and February in 2011/2012 as compared to the historical trend. Note the significant decrease in major trauma patients in May and January as compared to the previous years.

0% 10% 20% 30% 40% 50% 60% 70% 80%

2007/2008 2008/2009 2009/2010 2010/2011 2011/2012

Ground vs Air

Ground

Air

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

Mean 07/08 - 10/11 4.3 8.8 9.3 10.0 10.3 9.3 6.3 5.3 4.3 6.3 4.3 6.3

2011/2012 8 5 7 9 10 8 10 6 7 4 9 7

0.0

2.0

4.0

6.0

8.0

10.0

12.0

Comparison of ED Arrival by Month for 2011/2012 with 2007/2008 - 2010/2011


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Figure 23. Day of Arrival

In 2011/2012, there was an increase in major trauma patients arriving in ACH-ED on Sundays, Mondays and Tuesdays. The other days were less busy in 2011/2012 compared to the previous years, with the largest drop on Wednesdays and Thursdays. Time of Arrival Figure 24. Time of Arrival

Figure 24 shows increases in 2 of the time intervals with a significant increase in the 08:01-16:00. The majority of patients still arrive between 16:01-24:00.

Sun Mon Tues Wed Thu Fri Sat

Mean 07/08 - 10/11 13.3 11.8 7.8 12.0 11.3 15.3 13.0

2011/2012 26 13 11 9 8 12 11

49%

9% 29%

25% 29%

22% 15%

0.0

5.0

10.0

15.0

20.0

25.0

30.0

Comparison of Arrival by Day for 2011/2012 with 2007/2008 - 2010/2011

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

Mean 07/08 -10/11 12.0 23.8 48.5

2011/2012 12 29 49

18%

1%

0.0

10.0

20.0

30.0

40.0

50.0

60.0

Comparison of Time of Arrival for 2011/2012 with 2007/2008 - 2010/2011


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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) and shows the same pattern as in Figure 24; the majority arrived between 16:01-24:00. However the past two years has seen an increase in patients arriving in the 00:01-08:00 timeframe. This is an important indicator that will be monitored as most of the support services used by major trauma patients are on-call and not in-house during these hours. Patient Disposition from ED Figure 26.

Figure 26 shows the breakdown of patient disposition from the ED in 2011/2012 as compared to the historical trend. This past year, there was a significant increase in patients that were sent to the ward. There was one death in the ED in 2011/2012.

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

Mean 07/08 - 10/11 3.5 17.5 30.0

2011/2012 6 18 25

42%

3% 17%

0.0 5.0

10.0 15.0 20.0 25.0 30.0 35.0

Comparison of Patients Arriving Directly From the Scene for 2011/2012 with 2007/2008 -2010/2011

Died in ED 1%

ICU 31%

OR/ICU 3%

OR/Ward 2% Direct

Admit 8%

Ward 55%

Died in OR 0%

2011/2012

Died in ED 9%

ICU 38%

OR/ICU 6%

OR/Ward 3%

Direct Admit

8%

Ward 36%

Died in OR 0.3%

2007/2008 -2010/2011


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4. Patient Care Management Diagnostic Imaging Performed - 2011/2012 Table 3. Diagnostic Imaging A total of 68 patients (76% of major trauma patients) went urgently to CT for imaging of the following body locations. An additional 4 patients went to CT non-urgently. This is consistent with the 5 year average of 72% for urgent CTs for major trauma patients.

Diagnostic Imaging CT Locations

# Patients Percent of Total Patients (n=68)

Head 53 78% Abdomen 33 49% Pelvis 29 43% Chest 11 16% Spine 22 32% Face 11 16%

Note: Some patients had CTs done on multiple body locations.

Figure 27. Time of Day of Urgent CT

Figure 27 compares the time of urgent CTs from 2007/2008 to 2011/2012. 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 2011/2012, 60% (n=41) of patients who went to CT had CTs done from 16:01 to midnight. Only 13% of patients had CT’s from midnight to 8:00 AM, and 26% of patients had CT’s from 08:01 to 16:00.

9

19

45

10 11

28

4

18

34

8 13

37

9

18

41

0

10

20

30

40

50

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=68)

2007/2008 2008/2009 2009/2010 2010/2011 2011/2012


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Figure 28. Day of the Week CT performed

Figure 28 compares the day of the week CT was performed from 2007/2008 to 2011/2012. In 2011/2012 there is an increase in the CT’s performed on Sunday and Monday with a significant decrease on Thursday – which was also the day noted to be the largest decrease of arrival of major trauma patients. Non-Operative Procedures Performed in 2011/2012 Table 4. Non-operative Procedures Performed on Patients while in ACH-ED

Non-Operative Procedures # Patients Percent of Total Patients (n=90)

Gastric Tube Insertion 15 17% Foley Catheter Insertion 19 21% Intubation 6 7% Blood Product Administration 9 10% Chest Tube Insertion 3 3%

Surgical Procedures Table 5. Five-Year Trend 2007/2008 2008/2009 2009/2010 2010/2011 2011/2012 Total Major Trauma Patients 97 74 83 83 90 Total Patients Requiring Surgery 28 21 24 25 30 Total OR Visits 53 34 46 40 54 Total OR Hours 129 91 112 106 162 Mean (hours per case) 4.6 4.3 4.7 4.2 5.4 Mean (visits per case) 1.9 1.6 1.9 1.6 2.0

In 2011/2012 33% of trauma patients went to the OR. This is slightly above the 5 year average of 28%. Note the total OR hours significantly more this past year.

12

6

10 10

16

10 9 11

9 7

5 6 5 6 7 7 8 8 10

7 9

7

2 5

12 9

15

8

13

7 6 6 9

7

20

0

5

10

15

20

25

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

# of

Pat

ient

s

Day of the Week CT Performed

2007/2008 2008/2009 2009/2010 2010/2011 2011/2012


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Figure 29. Total Patients Requiring Surgery

In 2011/2012, a total of 30 (33%) patients required surgery during the patient’s stay in the hospital. 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. Table 6. OR Data by Service

OR Data by Service - 2011/2012

Physician Service # of Procedures Neurosurgery 7 Orthopedics 14 Pediatric General Surgery 5 Plastics 23

Figure 30. Time of Day to OR

Figure 30 compares the time patients went to the OR from 2007/2008 to 2011/2012. In 2011/2012, the majority of patients went to OR between 16:01-24:00.

2

14 12

3

11

6 4

10 10

5

12

8

1

12

17

0

5

10

15

20

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

Time of Day to OR

2007/2008 2008/2009 2009/2010 2010/2011 2011/2012

29% 28% 29% 30% 33%

0%

10%

20%

30%

40%

50%

2007/2008 2008/2009 2009/2010 2010/2011 2011/2012

# of

Pat

ient

s

Total Patients Requiring Surgery


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Length of Stay Statistics Figure 31. Patient LOS

Figure 31 compares the LOS of patients from 2007/2008 to 2011/2012. In 2011/2012, the median LOS for all patients is 5 days - consistent with the previous 5 year average of 5 days. A majority of patients (82%) stayed between 1 and 12 days, while 17% of patients stayed between 13 and 60 days. Admitting Physician Service Analysis – 2011/2012 Table 7.

In 2011/2012, a total of 36 patients (40%) were initially admitted to ICU. Those patients were subsequently transferred to the following:

6 patients went to Neurosurgery 10 patients went to Pediatrics 17 patients went to General Surgery 3 died in ICU

* Note that one patient was initially admitted under General Surgery but due to instability was transferred to PICU for management of care and then transferred back out under General Surgery. ** Note that two patients were initially admitted under General Surgery but transferred to Orthopedics for management of care.

0%

10%

20%

30%

40%

50%

1-3 4-6 7-12 13-60 61-98 99-202

Perc

enti

le o

f Pat

ient

s

Number of Days

LOS by Percentile of Patients

2007/2008 2008/2009 2009/2010 2010/2011 2011/2012

Physician Service # Patients Initially

Admitted to Service

Percent of Total

Patients Admitted

n=89 (1 died in ED)

# Patients Transferred to Service

Total Trauma Cases

per Service

Total Days on Service

Mean LOS on Service

Median LOS on Service

ICU 36 40% 1* 37 163 4 1 Neurosurgery 20 23% 6 26 77 4 2

Orthopedics 0 0% 2** 2 10 5 5 Pediatrics 7 8% 10 17 274 15 14 General Surgery 25 28% 17 42 248 6 5

Plastics 1 1% 0 1 1 1 1


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Hospital Discharge Destination Figure 32. Discharge Destinations

Figure 32 shows that more patients went to another acute care facility or home to children’s aid/foster care in 2011/2012 as compared to the historical trend. Note this year there were 3 patients that were transferred to another facility to be closer to family. Outcomes by Age Figure 33. Survivors

Figure 33 compares all age groups of survivors.

Another Acute Care

Facility

Children's Aid/Foster

Care Died Home

Home with Support Services

Other Rehab Facility

Mean 07/08 -10/11 0.5 3.25 7 71.75 1.25 0.25 0.25

2011/2012 3 5 4 78 0 0 0

0 10 20 30 40 50 60 70 80 90

Comparison of Discharge Destination for 2011/2012 with 2007/2008 - 2010/2011

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

Mean 07/08 - 10/11 11 12.5 13.25 29.25 11.25

2011/2012 12 20 15 31 8

0 5

10 15 20 25 30 35

Comparison of Survivors by Age Group for 2011/2012 with 2007/2008 - 2010/2011


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Figure 34. Non-Survivors

Figure 34 shows 4 deaths in 2011/2012.

Outcomes by ISS – 2011/2012 Figure 35. Survivors vs Non-Survivors by ISS

Most survivors (69%, n=59) had ISS from 16 to 25. Most non-survivors were in the ISS range 16-25 with 3% death rate, followed by ISS 26-35 with 7% mortality rate and ISS range 36-45 with 14% mortality rate.

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

Mean 07/08 - 10/11 1.25 2.75 1.25 1.25 0.5

2011/2012 1 2 1 0 0

0

0.5

1

1.5

2

2.5

3

Comparison of Non-Survivors for 2011/2012 with 2007/2008 - 2010/2011

8

59

13 6

0 2 1 1 0

10

20

30

40

50

60

70

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

# of

Pat

ient

s

ISS

2011/2012

Survivors Non-Survivors


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TRISS Pre Charts for 2011/2012 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 36. Pediatric Pre Charts include blunt and penetrating mechanisms for patients < 15 years. Report generated on 11/07/2012 Range From 01/04/2011 to 31/03/2012 Query is EVERYONE 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 + ............................D......... + A | ......................................... | 5 + ........................................... + 5 S | ............................................. | C + ................................................ + O | .................................................. | R 6 + ..................................................... + 6 E | ....................................................... | + ................L......................................... + | ...............L.L......L................................... | 7 + ...............L.........L.........L.......................... + 7 | ................................................................. | + ...............LL...LL...L........L................................ + | ............LL.LL..LLL..LL..L..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 was 1 unexpected death for patients less than 15 years in 2011/2012 using the TRISS methodology. This was reviewed at the Pediatric Trauma Quality Management Committee, as well as at Mortality and Morbidity rounds, and management was deemed appropriate.


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Figure 37. Adult Pre Charts include blunt and penetrating mechanisms between 15 and 17 years.

Report generated on 11/07/2012 Range From 01/04/2011 to 31/03/2012 Query is EVERYONE 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 + ...............LL............................................. + 7 | ................................................................. | + ................................................................... + | .............L.L........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 2011/2012 using the

TRISS methodology.

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