ach pediatric trauma program, annual report 2015 · pediatric trauma program . annual report . 2015...

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ALBERTA CHILDREN’S HOSPITAL

PEDIATRIC TRAUMA PROGRAM

ANNUAL REPORT

2015

ACH Trauma Program Staff

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

Dr. Steve Lopushinsky ................................................ In-Patient Surgical Lead

Sharleen Luzny ........................................................ 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 ....................................................................................... 14

6. Future Planning .......................................................................................... 15

APPENDICES

Appendix A Trauma Quality Indicators .......................................................... 16 Appendix B Major Trauma Statistics…. ................................................. ….. 33

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1. Introduction The Pediatric Trauma Program celebrates another productive and successful year. We have continued to strive to implement and maintain all of the recommendations made in the previous Trauma Association of Canada Accreditation. Over the coming year, we will begin preparation for our upcoming re-accreditation through Accreditation Canada. We welcome this opportunity to ensure that we continue to deliver the highest level of care to the children of Southern Alberta. The ACH Trauma Program strives to achieve excellence across the entire spectrum of trauma care. As is easily over looked, this begins with prevention. The program is a vocal injury prevention advocate 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), of which ACH is a partner, we are able to monitor injury trends and target areas of intervention. One such intervention stemmed from the recognition of the frequency with which children fall from second storey windows, particularly in the summer. An amendment to the building code was submitted this past year which aims 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 and more importantly to petition 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. Typically, the first point of care for an injured child is our Emergency Medical Services (EMS) team, whom the ACH trauma program would like to give a heartfelt thank you. These men and women provide exceptional care with limited resources in the most austere environments and we are greatly appreciative of the work they do. We are in regular communication with EMS from the solidification of destination guidelines to the recent change in spinal motion restriction policies. They frequently attend our various meetings, so that together we can optimize the pre-hospital care of pediatric patients. As is the case throughout Canada, many of the most severe injuries do not occur within the limits of a major city. These children are first assessed and stabilized in smaller centers and then, if required, are transported to the Alberta Children’s Hospital. The broad geography of Southern Alberta and the disparate allocation of resources pose significant logistical challenges for the care of these patients. 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. Upon arrival to ACH, the trauma patient is 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 when these patients need us the most. The Trauma Team Leader (TTL) is a designated Emergency Physician

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currently on shift whose first priority is to manage resuscitations in the Trauma Bay. As these trauma shifts are covered 24/7 there is never a delay in arrival of a TTL as would be the case in an on-call TTL system. The Trauma Surgery Team is of course an integral part of the team, responding to all trauma activations and co-managing the patient along side the TTL and 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. In addition to a Trauma Team Activation, we have also developed 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. The anesthesiologist comes to the Trauma Bay immediately to assist with airway management if needed and to help facilitate definitive care for the patient in the OR. A child with multi-system injuries may also require the services of multiple other disciplines such neurosurgery, orthopedic surgery, otolaryngology or plastic surgery, but to name a few. As one can well imagine, the coordination of all of these disciplines for a critically injured child with competing medical issues can at times pose quite a challenge. The ACH Trauma Program continually endeavors to bridge these gaps and to optimize seamless care for these patients. We have broad subspecialty representation at our monthly Trauma Committee meetings which serve as a forum to share any concerns and make recommendations to further optimize our system. We run regular mock trauma codes that involve the entire trauma team, beginning in the trauma bay and continuing to the OR. The fidelity of these simulations has been impressive, with outstanding buy-in from all participants. These events serve to further foster the close working relationship and teamwork among the various specialties caring for these patients. They also allow us to practice the transition of care between physical locations such as from the trauma bay to the OR. One of the big learning points highlighted was the need for the emergency trauma team and TTL to accompany an unstable patient up to the OR and to continue leading the resuscitation while the surgical and anesthesiology team prep the room and focus on the surgery at hand. We enjoy a great working relationship with our radiology department who also respond to all trauma activations, providing timely access to diagnostic imaging 24/7. The radiology department has committed to providing attending reads of all trauma activations within the hour, in an effort to minimize discrepancies between preliminary and final reports. The radiology department has also committed to providing 24/7 interventional radiology support, a weakness that was identified during our last accreditation. The backbone of our trauma team is our amazing nurses. The strongest, most capable nurses in the emergency department compose the team. They have the patient on monitors, with IV access and have anticipated the next steps in management reflexively. They have the opportunity to maintain their skill set through the Trauma Nursing Core

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Course (TNCC) that is provided bi-annually and through 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. 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. Inpatient 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. Over the past year, we have shown that an accelerated pathway for children with blunt abdominal injuries (liver, spleen and kidney) is safe and reduces both length of hospital stay and the number of blood draws. We look forward to sharing this data with other pediatric centres around the country. Finally, we look forward to welcoming an international leader in pediatric trauma, Dr. Natalie Yanchar to our team in October 2016. Dr. Yanchar is the current President of the Trauma Association of Canada (TAC) and is highly regarded for her advocacy in ATV legislation. The Brain Injury and Rehabilitation Program continues to provide services for patients who have suffered traumatic brain injuries. This program includes inpatient comprehensive rehabilitation services, as well as outpatient in coordination with Gordon Townsend School. The program is well suited for children in the school system. Trauma patients aged 15-17yrs old that are initially treated at the FMC may be transferred to ACH for our program, as it helps integrate children back into the school system. ‘Curious About Concussion?’ is a clinical education session for patients and families that has been available for patients with mild traumatic brain injury for the past year. This program continues to grow with plans for better ways to disseminate the information to the public (ie online video or conference). Education has always been one of the great strengths of this Trauma Program, which we continue to build upon. Our trauma educators have once again provided outstanding teaching throughout the year. In 2015, the ACH Trauma Program provided 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 KidSIM™, the Pediatric Human Patient Simulation Program at ACH. Our newest educational initiative is the development of a 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 RT to enhance the realism

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of the scenario. This has been coupled with a new ACH Pediatric Airway Course that most of the physician group has completed. In addition, a concerted effort has been made to teach bedside ultrasound skills to our physician group and we expect that most will have their formal ultrasound certification complete within the next year. 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 our Trauma Coordinator Ms. Sherry MacGillivray who was recently elected to the TAC Board of Directors. 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. The multidisciplinary team of nurses, physicians, respiratory therapists, and other front-line staff remain devoted to the care of these children and their families. 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 tremendous dedication and commitment to our Pediatric Trauma Program. 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:

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. In 2015 the Trauma Committee reinforced the importance of this consolidation for major trauma patients.

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. There were no significant changes in 2015.

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’ and ‘missed’ call and for any issues that arise. Evidence suggests the over call may have to be as high as 50% to keep the missed calls <5%. See Appendix B for 2015 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.

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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 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 2015 completion rate was 90%.

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 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.

xi) Trauma Beading Program

• Thanks to a generous grant from the Alberta Children’s Hospital Foundation, the Trauma Beading Program for major trauma patients remains on-going. 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.

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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.

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

• February 26, 2015 – Dr. Michael Driedger “Pediatric Trauma

Laparotomies: Role and Outcomes”

• March 26, 2015 – Tina Samuel & Lisette Lockyer “Curious About Concussions?”

• May 28, 2015 – Dr. Jennifer Leighton “Pediatric Elbow Injuries- Pears and Pitfalls”

• June 25, 2015 – Dr. Ramdas Senasi “Imaging in Abdominal Trauma”

• September 24, 2015 – Dr. Nina Hardcastle “TBI Management in the OR Setting: Case Presentation”

• October 22, 2015 – Dr. Arunbabu Rajeswaran “Pediatric Skull Fractures”

• November 26, 2015 – Dr. Michael Szava-Kovats “The Good, the Bad and the Ugly: Whole Body CT Imaging in Trauma”

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.

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. This past year, one of the mocks started in the ED with a full activation of both code 77 and 88 then moved up to the OR. It involved the entire OR team as well as General Surgery.

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.

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The following centres were visited in 2015:

March 2015 Strathmore, Didsbury April 2015 Cardston, Fort McLeod May 2015 Sundre, Brooks June 2015 Cranbrook BC Sept 2015 Red Deer, Brooks Oct 2015 Lethbridge, Claresholm Nov 2015 Banff Dec 2015 Crowsnest Pass

v) Emergency Department Trauma Simulation Sessions • Trauma simulation sessions were 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 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) Advanced Trauma Procedural Skills Lab • Through the collaboration of the Trauma Program and the ECMO program

at ACH this attending-focused lab allowed participants to practice advanced procedures including chest tube insertion, emergent thoracotomy and surgical airways.

viii) Emergency Medicine for Rural Hospitals (Banff AB - Jan 2015) • “Challenging Pediatric Trauma Cases” – Sherry MacGillivray

ix) Pediatric Care Update (Calgary, AB – April 2015)

• “Trauma Update and Challenging Cases” – Sherry MacGillivray

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

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• 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 2015:

PUBLICATIONS:

1) Russell K, Meeuwisse WH, Nettel-Aguirre A, Emery CA, Gushue S, Wishart J, Romanow N, Rowe BH, Goulet C, Hagel BE. Listening to a personal music player and odds of injury among snowboarders in a terrain park: a case-control study. British Journal of Sports Medicine July 2015; 49:1 62-66.

2) Barlow KM, Crawford S, Brooks BL, Turley B, Mikrogianakis A. The Incidence of Post Concussion Syndrome Remains Stable Following Mild Traumatic Brain Injury in Children. Pediatric Neurology 2015 Dec 03;53(6); 491-7

3) Khetani A, Brooks B, Mikrogianakis A, Barlow KM. Incorporating a Computerized Cognitive Battery into the Emergency Department Care of Pediatric Mild Traumatic Brain Injuries – is it feasible? Pediatric Emergency Care. 2015 Dec 07

4) Brooks B, Daya H, Khan S, Carlson H, Mikrogianakis A, Barlow KM. Cognition in the Emergency Department as a Predictor of Recovery after Pediatric Mild Traumatic Brain Injury. Journal of the International Neuropsychological Society. 2015 Dec 07;21:1-9.

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) 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.

4) 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.

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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. No changes were made this past year. ACH performance indicators for 2015 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 2016 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 and growth of an Attending Physician focused, CME accredited, simulation based, professional development program

ACH Trauma Quality Indicators (ISS>12) 2015

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Appendix A Alberta Children’s Hospital Trauma Quality Indicators for 2015 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

2015 n = 63 62 1 2014 n = 76 71 5 2013/2014, n = 80 79 1 2012/2013, n = 62 62 0 2011/2012, n = 77 71 6

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.

Indicator Yes No 2015 n = 18 8 10 2014 n = 12 2 10 2013/2014, n = 19 5 14 2012/2013, n = 10 5 5 2011/2012, n = 11 2 9

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.

Indicator Yes No

2015 n = 25 15 10

2014 n = 30 20 10

2013/2014, n = 37 27 10

2012/2013, n = 28 19 9

2011/2012, n = 33 20 13

If at any time the 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 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 or Stollery Hospitals in Edmonton. As well as Red Deer, Lethbridge or Medicine Hat Hospitals. Exclusions: Out of the patient transfers, 10 patients were transferred from within Calgary, 4 from Lethbridge, 2 from Red Deer and 1 from Medicine Hat resulting in a total (n= 16) of 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 2015 n = 16 5 11

2014 n = 13 5 8

2013/2014, n = 24 6 18

2012/2013, n = 13 7 6

2011/2012, n = 22 9 13

A high number of 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, but it is still not a mandatory service in Alberta. This


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indicator has also been a priority for Alberta Trauma Services. Note that one patient did not have a known time of injury this past year. 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 2015 n = 34 8 26

2014 n = 38 10 28

2013/2014, n = 43 13 30

2012/2013, n = 31 7 24

2011/2012, n = 42 9 33

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.


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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 guidelines were reviewed and ‘tightened up’ last in September 2013 which resulted in less overall activations and less ‘overcall’ of the trauma team. 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. In the past year, the total Code 77 activations for all patients (regardless of ISS) was 76 (compared to an average of 139 prior to the 2013 changes). ‘Overcall’ (those not admitted) was 29%. ‘Missed call’ (those that should have had an activation according to guidelines) was only 4%. We also monitor for ‘undercalls’, i.e. those patients that did not meet activation criteria but did have significant injuries and we have not found a significant number of ‘undercalls’ since the implemention of our revised activation criteria. The over, under and missed call of Code 77 patients is monitored closely by the Pediatric Trauma Coordinator and reported monthly at the Trauma Committee.

Major Trauma Team Activation

4 4 4

65

2 23

2

6 6

12

3

5

34

5

34 4

1

3

11

32

6

3

1 1

3

5

2

01

01

2

45

7

5 54

23

1

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

# of

Act

ivat

ions

2012/2013 2013/2014 2014 2015


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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 2015 n = 66 9 57 2014 n = 96 6 90 2013/2014, n = 93 6 87 2012/2013, n = 76 4 72 2011/2012, n = 89 7 82

There is currently a No Direct Admit Policy for trauma patients – meaning they should stop in the ED for assessment. This policy was made to ensure that every patient gets an unbiased, good primary survey. If a patient had been admitted to a referral hospital for more than 24 hrs prior to the transfer this policy does not apply. This past year three patients were appropriately transferred post operatively from a Level 3 trauma centre. Two were sent after multiple days of admission for further management. One had no history of trauma. One presented to a referral centre multiple days post injury. The remaining two were discussed at the Pediatric Trauma Quality Management Committee and should have stopped in the ED and recommendations have been made by the Committee. Of note, 6 of the 9 patients were directly admitted to PICU. 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

2015 n = 2 2 0

2014 n = 4 4 0

2013/2014, n = 5 5 0

2012/2013, n = 2 2 0

2011/2012, n = 0 0 0

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


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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

2015 n = 57 28 29

2014 n = 90 36 54

2013/2014, n = 89 35 54

2012/2013, n = 72 34 38

2011/2012, n = 83 30 53

ED documentation continues to be a challenge 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 hourly standard. Next year this indicator will be changed to hourly documentation to meet new guidelines from the National Trauma Data Bank submission. 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

2015 n = 48 44 4

2014 n = 74 54 20

2013/2014, n = 79 61 18

2012/2013, n = 59 44 15

2011/2012, n = 65 47 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. This indicator has improved post awareness to the ED nurses.


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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

2015 n = 57 1 56

2014 n = 89 3 86

2013/2014, n = 88 3 85

2012/2013, n = 67 2 65

2011/2012, n = 79 1 78

This past year there was one patient that presented to the ED hypothermic where rewarming was done appropriately. Six patients did not have their temperature documented in the ED over the year – this will be an education priority going forward. 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

2015 n = 4 4 0

2014 n = 4 4 0

2013/2014, n = 19 19 0

2012/2013, n = 14 14 0

2011/2012, n = 14 13 1


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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

2015 n = 57 31 26

2014 n = 90 44 46

2013/2014, n = 89 46 43

2012/2013, n = 72 40 32

2011/2012, n = 81 40 41

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. 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

2015 n = 65 63 2

2014 n = 96 87 9

2013/2014, n = 93 85 8

2012/2013, n = 74 66 8

2011/2012, n = 89 82 7

Two patients were appropriately admitted to the Pediatrics Team according to the admission guidelines for head injuries less than one year of age and NAT cases.


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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

2015 n = 2 2 0

2014 n = 3 3 0

2013/2014, n = 7 5 2

2012/2013, n = 3 2 1

2011/2012, n = 3 3 0

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

2015 n = 65 0 65

2014 n = 96 0 96

2013/2014, n = 93 3 90

2012/2013, n = 74 0 74

2011/2012, n = 89 0 89


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17. Any laparotomy procedure performed.

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

Indicator Yes No

2015 n = 66 4 62

2014 n = 96 3 93

2013/2014, n = 95 2 93

2012/2013, n = 76 2 74

2011/2012, n = 90 4 86

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. 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

2015 n = 5 4 1

2014 n = 3 3 0

2013/2014, n = 3 3 0

2012/2013, n = 4 4 0

2011/2012, n = 7 6 1

One patient went to the OR after 24 hours but had traction intact prior to same. This case was discussed at the Trauma Quality Management Committee where care was deemed timely and appropriate. Keep in mind the total n femur fractures is for ISS > 12 patients only – isolated femur fractures do not qualify.


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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

2015 n = 0 0 0

2014 n = 1 1 0

2013/2014, n = 0 0 0

2012/2013, n = 1 1 0

2011/2012, n = 2 1 1

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

2015 n = 23 0 23

2014 n = 28 1 27

2013/2014, n = 27 0 27

2012/2013, n = 20 1 19

2011/2012, n = 30 0 30


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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

2015 n = 65 1 64

2014 n = 96 2 94

2013/2014, n = 93 4 89

2012/2013, n = 74 1 73

2011/2012, n = 89 0 89

A trauma tertiary survey (TTS) 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. This past year one patient’s radius/ulna fractures were found once ambulation with a walker was initiated. 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

2015 n = 1 1 0

2014 n = 1 1 0

2013/2014, n = 0 0 0

2012/2013, n = 1 0 1

2011/2012, n = 3 2 1


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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

2015, n = 0 0 0

2014, n = 0 0 0

2013/2014, n = 0 0 0

2012/2013, n = 0 0 0

2011/2012, 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.

Indicator Yes No

2015 n = 1 1 0

2014 n = 3 3 0

2013/2014, n = 1 1 0

2012/2013, n = 3 3 0

2011/2012, n = 1 0 1


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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

2015 n = 4 4 0

2014 n = 1 1 0

2013/2014, n = 2 2 0 2012/2013, n = 0 0 0

2011/2012, n = 0 0 0

Three of these patients this past year were sent to the Foothills Medical Centre for their spinal surgery. This is considered best practice by the ACH Orthopedics division in collaboration with the Foothills Spine service. 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

2015 n = 0 0 0

2014 n = 0 0 0

2013/2014 n = 0 0 0

2012/2013 n = 0 0 0

2011/2012 n = 0 0 0


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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

2015 n = 0 0 0

2014 n = 0 0 0

2013/2014 n = 0 0 0

2012/2013 n = 0 0 0

2011/2012 n = 1 0 1

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

2015 n = 65 0 65

2014 n = 96 0 96

2013/2014, n = 93 2 91

2012/2013, n = 74 2 72

2011/2012, n = 89 1 88


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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

2015 n = 28 1 26

2014 n = 33 0 33

2013/2014, n = 39 0 39

2012/2013, n = 24 0 24

2011/2012, n = 36 3 33

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 due to deteriation which was identified by the STEP team process. 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

2015 n = 9 6 3

2014 n = 6 1 5

2013/2014, n = 5 3 2

2012/2013, n = 5 2 3

2011/2012, n = 4 3 1

This past year one patient died in the ED and five in the PICU within 24 hours of admission: Two children from severe head injuries post MVC, one child from severe head injuries resulting from non-accidental or intentional injury, one child from severe head, lungs and abdominal injuries from skiing, one child from accidental strangulation, and one child from a tracheal injury resulting from an ATV collision.


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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

2015 n = 66 9 57

2014 n = 96 6 90

2013/2014, n = 95 5 90

2012/2013, n = 76 5 71

2011/2012, n = 90 4 86

Three additional patients died after 24 hours this past year: one child from drowning, one from severe head injuries resulting from non-accidental or intentional injury, and one from severe head injuries resulting from a fall. All death cases were reviewed by the Pediatric Trauma Quality Management Committee and care was deemed appropriate.

ACH Major Trauma Statistics (ISS>12) 2015

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APPENDIX B Major Trauma Statistics for 2015

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 Outcomes by Age and ISS TRISS Pre-Charts


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

2011/2012 2012/2013 2013/2014 2014 2015 Total Patients

90 76 95 96 66

Males

57 63.3%

48 63.1%

57 60.0%

59 61.4%

31 47.0%

Females

33 36.7%

28 36.8%

38 40.0%

37 38.5%

35 53.0%

Total Length of Stay (LOS) (days)

812 502 765 827 1078

Median LOS

5 4 5 5 5

Mean LOS

9 7 8 9 16

Total Emergency Department (ED) LOS (hours)

397.6 318.4 402.9 390.5 234.8

Median ED LOS (hours)

3.4 3.4 3.5 4.0 3.5

Mean ED LOS (hours)

4.9 4.1 4.3 4.3 4.1

ICU Admissions

37 41.1%

25 32.8%

39 41.0%

33 34.3%

28 42.4%

Median ICU LOS (days)

1 2 2 2 3

Mean ICU LOS (days)

4 4 3 4 6

Total ICU LOS (days)

163 90 125 143 179

Median ISS

16 23 19 18 21

Mean ISS

21 23 24 22 23

Direct Admits

7 4 6 6 9

Referrals to ACH from other centres

40 44.4%

31 40.8%

43 45.2%

38 39.6%

34 51.5%

Deaths 4 4.4%

5 6.6%

5 5.2%

6 6.3%

9 13.6%

In 2015, 66 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 85 major trauma patients seen annually. This decrease is due to upgrading to the AIS 2005 coding system on January 1, 2015 in order to prepare for submission to the National Trauma Data Bank based in the US in the near future.

This 2015 trauma volume represents 7.4% of all patients admitted to the ACH with injuries (n=888), which is a 3.3% decrease from last year.


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Interestingly this year, the percentage of major trauma patients who are females (53.0%) were greater than males (47.0%).

Major trauma patients referred in from other centers represented 51.5% of the major trauma

volume for 2015. This is significantly higher than the five-year average of 44.3%. Length of stay for major trauma patients ranged between 1 and 206 days. Mean LOS of 16 days

is higher than the five-year trend of 10. Median LOS of 5 days is consistent with the five-year trend of 5. The total ED LOS was 234.8 hours, and lower than the five-year average of 349.6 hours. Both

the mean and median LOS were consistent with the five-year averages of 4.3 and 3.6 respectively. 42.4% of major trauma patients were admitted to the ICU, which is slightly higher than the five-

year average of 38.3%. Total ICU LOS was 179 days, which is higher than the five-year average of 140. The mean ICU LOS (6) is slightly higher than the five-year average of 4.2 and the median is consistent at 2.

Both the mean (23) and median (21) ISS for major trauma patient from 2015 were slightly higher

than the five-year averages of 22.6 (mean) and 19.4 (median). A total of 9 deaths were seen in major trauma patients in 2015. This represents 13.6% of major

trauma volume, and is higher than the five-year average of 7.2%.


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Figure 1. Age and Gender Distribution for ACH Major Trauma Patients for 2015

Figure 1 shows the number of males and females for the above age groups. In 2015 the majority of trauma patients were female. Though on average, males comprised 59.0% of the major trauma population over a period of five years. Figure 2a. Age Distribution of <15 year olds admitted to Calgary Adult Hospitals

Figure 2a shows there was one pediatric patient less than 15 years old treated at a Calgary adult hospital this past year, as compared to 2014. EMS protocols dictate ‘closest hospital’ when there is an airway issue or ongoing resuscitation. All cases are reviewed by the Trauma Coordinator to deem appropriateness.


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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 the Foothills Medical Centre (FMC). In the past the eventual assumption of this age group was a priority for the ACH Pediatric Trauma Program, however due to capacity issues and surgical funding assuming this age group is no longer a priority. The ACH ED RN answering the EMS patch phone should re-direct to the FMC ED if Trauma Team Activation - Code 77 criteria is met.


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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 2015 as compared to the historical trend. The biggest change this past year was an increase in transport related injuries and a decrease in falls.


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Mechanism of Injury – Transportation Figure 4. Transportation Statistics

Figure 4 shows the breakdown of transportation-related injuries in 2015 as compared to the historical trend. Note: MRV is motorized recreational vehicle. A total of 33 patients (50% of major trauma patients) were involved in transportation-related incidents in 2015.

Mortality: 9% 3 patients died. ISS ranged from 12 to 51. Mean ISS was 23 and median ISS was 18.

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

Figure 5 shows a significant 21% increase in transportation-related incidents from 2014 to 2015.


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Figure 6. Transportation by Age Group

Figure 6 shows the breakdown of transportation incidents by age groups in 2015 as compared to the historical trend. Increases are noted in the <1 yr and >14 yr categories.

In 2015: Age Group <1 (n=2, 6%) included 2 passengers. There were 2 deaths in this age group. Age Group 1-4 (n=3, 9%) included 2 passengers and 1 pedestrian. Age Group 5-9 (n=11, 33%) included 3 passengers, 4 pedestrians and 4 cyclists. Age Group 10-14 (n=11, 33%) 4 passengers, 2 cyclists, 3 pedestrians and 2 ATV related injuries.

There was 1 death in this age group. Age Group > 14 (n=6, 18%) included 2 cyclists and 2 drivers, 1 ATV and 1 snowmobile related injury.


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Mechanism of Injury – Falls Figure 7. Statistics for Falls as the MOI Figure 7 shows the breakdown of falls incidents in 2015 as compared to the historical trend. There has been a 5% increase in multi-level falls which includes: falls from second storey windows, falls while being carried, falls off horses and falls from playground equipment.

A total of 12 patients (18% of major trauma patients) were admitted for fall-related injuries.

Mortality: 0% all patients survived. ISS ranged from 14 to 38. Mean ISS was 21 and the median ISS was 17.

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 well below the five year average of 30%.


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Figure 9. Falls by Age Group

Figure 9 shows the breakdown of fall incidents by age groups in 2015 as compared to the historical trend. A significant decrease is seen in the <1 yr old age group and significant increase in the 5-9 age group.

In 2015: Age Group <1 (n=1, 8%) Patient fell while being carried. Age Group 1-4 (n=2, 17%) included 2 multi-level falls. Age Group 5-9 (n=6, 50%) included 2 multi-level falls, 1 same level falls, 2 falls out of buildings and 1

fall on stairs. Age Group 10-14 (n=3, 25%) included 2 multi-level falls and 1 falls on same level. Age Group >14 (n=0, 0%) no patients in this age group.


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Mechanism of Injury – Violence Figure 10. Violence as the MOI Figure 10 shows the breakdown of violence-related incidents in 2015 as compared to the historical trend. Note the increase in self-inflicted injuries this past year (14% = 1 patient)

A total of 7 patients (11% of major trauma patients) were admitted for violence-related injuries.

Mortality: 42% 3 patients died. ISS ranged from 16 to 42. The mean ISS was 26. The median ISS was 26.

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

Figure 11 shows a decrease in violence related injuries over the past year.


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Figure 12. Violence Incidents by Age Group

Figure 12 shows the breakdown of violence incidents by age groups in 2015 as compared to the historical trend. Note the large increase of 1-4 yr olds with the subsequent decrease in the >1 yr old and 10 to 14 yr old age groups.

Age Group <1 (n=2, 29%) Both were non-accidental trauma or intentional injury in this age category.

1 patient died in this age category. Age Group 1-4 (n=3, 43%) All 3 were non-accidental trauma or intentional injury in this age category. Age Group 5-9 (n=1, 14%) 1 non-accidental trauma or intentional injury. Patient died. Age Group 10-14 (n=0, 0%) no patients in this age category.


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

Figure 13 shows the breakdown of other mechanism of injuries in 2015 as compared to the historical trend. There were no fire & explosion related injuries this year. However, there was an increase in inhalation & ingestion related injuries and a decrease in submersion & drowning injuries this year. A total of 14 patients (21% of major trauma patients) were admitted for other mechanism of injuries.

Mortality: 21% 3 patients died. ISS ranged from 14 to 57. For survivors, the mean ISS was 18 and the median ISS was 25. For non-survivors, the mean ISS was 25 and median ISS was 25.

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

Figure 14 shows a slight decrease 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%.


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Figure 15. Other Mechanism by Age Group

Figure 15 shows the breakdown of incidents involving other mechanism of injury by age groups in 2015 as compared to the historical trend. There was increase in 10-14 yr olds and a decrease in <1 and 1-4 yr olds. In 2015: Age Group <1 (n=0, 0%) no patients in this age category. Age Group 1-4 (n=3, 21%) included 1 submersion injury, 1 struck accidentally by object and 1

inhalation & ingestion injury. There was one death in this age category. Age Group 5-9 (n=4, 29%) included 1 animal related injuries and 3 striking accidentally against

objects or persons. There was one death in this age category. Age Group 10-14 (n=6, 43%) included 3 striking object or person accidentally, 2 animal related

injuries and 1 mechanical suffocation injury. There was one death in this age category. Age Group >14 (n=1, 7%) included 1 striking object accidentally.


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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 2015. Blunt injuries comprised 94% of major trauma population. This has been consistent over the past 5 years as seen in figure 17. Figure 17. Five-Year Trend for Type of Injury

Figure 17 compares the different types of injuries from 2011/2012 up to 2015.


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On April 1, 2012 all AHS trauma centers began capturing data on all penetrating traumas regardless of ISS in the Alberta Trauma Registry. In 2015 there were 4 penetrating traumas. Place of Injury Figure 18. Statistics for Place of Injury

Figure 18 shows where the patients were injured in 2015 which showed a decrease in the home/residential category this past year and a significant increase in street.


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3. Referrals and Emergency Management Referral Patterns

Out of 423 major trauma patients from 2011/2012 to 2015, a total of 186 patients (44%) 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 27 patients (15% of total referrals) and Red Deer Regional Hospital with a total of 19 patients (10% of total referrals) over five years. Medicine Hat and Cranbrook 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 2011/2012 2012/2013 2013/2014 2014 2015 Total

Region 1 - Chinook Health Region, Total = 46 Blairmore - Crowsnest Pass 1 2 3

Cardston – Municipal 2 1 3 1 7

Fort Macleod H.C.C. 1 3 4

Lethbridge Regional 6 7 5 5 4 27

Pincher Creek Municipal 1 1

Taber H.C.C. 1 2 1 4

Region 2 - Palliser Health Region, Total = 18 Bassano General 1 1

Brooks Health Centre 1 1 2

Medicine Hat Regional 2 2 3 5 1 13

Region 3 - Calgary Health Region, Total = 58 Banff - Mineral Springs 4 1 1 3 9

Black Diamond – Oilfields General 1 1 1 3

Calgary – Foothills 2 1 1 1 2 7

Calgary – General/Peter Lougheed 2 1 1 2 3 9

Calgary – Rockyview General 2 1 1 4 1 9

Calgary – South Health Campus 3 1 3 7

Canmore General 1 1 2

Claresholm General 1 1 2

High River General 2 1 3

Strathmore - Valley General 1 3 4

Cochrane Urgent Care 1 1 2

Okotoks Urgent Care 1 1


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Region 4 - David Thompson Health Region, Total = 36 Didsbury – Mountain View H.C. 1 1

Drumheller Regional 1 1 1 1 4

Hanna H.C.C. 1 1

Olds General 1 1 2

Red Deer Regional 4 3 4 6 2 19

Rocky Mountain House 1 2 1 4

Stettler General 1 1

Sundre General 1 1 2

Three Hills H.C.C. 1 1 2

Other Alberta Hospitals, Total = 1

University of Alberta Hospital 1 1

British Columbia, Total = 25 Cranbrook Regional Hospital 1 5 5 1 12

Elkford Health Centre 1 1

Fernie District Hospital 1 1 3 1 6

Golden & District General Hospital 1 1

Invermere District Hospital 1 1 1 3

Penticton Regional Hospital 1 1

Salmon Arm, Shuswap Hospital 1 1

Saskatchewan, Total = 2

Royal University Hospital, Saskatoon 1 1

Regina 1 1

Out of Country, Total = 2

Egypt 1 1

Mexico 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 2015 as compared to the historical trend. Note the increase in helicopter transports for direct from the scene patients and decrease in private vehicle/walk-in patients.

Figure 20. Referrals

Figure 20 shows the patients who were referred to ACH for further treatment in 2015 as compared to the historical trend. Note the increase in helicopter and private vehicle transports for referral patients this past year. Means of transport is part of the review process for each major trauma patient to ensure the patient comes to ACH the safest way possible.


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Figure 21. Ground vs Air

Ground ambulance transported 43 patients (65%) major trauma patients in 2015, which is slightly higher than the previous fiscal year. Their ISS was a mean of 21 and median of 18. Figure 21 also shows the increase in the use of air transport by 11% in 2015. Patients transported by air had an ISS mean of 30 and median of 27. 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 with the exception of May, July, November and December in 2015 as compared to the historical trend.


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Figure 23. Day of Arrival

In 2015, there was an increase in major trauma patients arriving in ACH ED on Mondays and Thursdays. The other days were much less busy in 2015 compared to the previous years. Time of Arrival Figure 24. Time of Arrival

Figure 24 shows marked decreases in all time categories. This is most likely due to decreased number of overall patients using AIS 2005 coding. The majority of patients arrive between 16:01-24:00.


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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.

Diagnostic Imaging Performed in 2015 Table 3. Diagnostic Imaging A total of 49 patients (72% of major trauma patients) went urgently (within 6 hours of arrival) to CT for imaging of the following body locations. This is slightly lower than the 5 year average of 74% for urgent CTs for major trauma patients.

Diagnostic Imaging CT Locations

# Patients Percent of Total Patients (n=48)

Head 30 61% Abdomen 38 78% Pelvis 38 78% Spine 34 69% Chest 21 44% Face 3 5%

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


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Figure 26. Time of Day of Urgent CT

Figure 26 compares the time of urgent CTs from 2011/2012 to 2015. 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 2015, 54% (n=26) 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 33% 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 2011/2012 to 2015. In 2015 there is a significant increase in the CT’s performed on Thursday and Sunday with a decrease on all other days.


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Figure 28. CT done within 1 hour of ED Arrival

Figure 28 shows the past two years comparisons if CT was done within one hour of arrival at ACH ED. In 2015 44% 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 2015 Table 4. Non-operative Procedures Performed on Patients while in ACH ED

Non-Operative Procedures # Patients Percent of Total Patients (n=57)

Gastric Tube Insertion 11 19% Foley Catheter Insertion 13 23% Intubation 3 5% Blood Product Administration 2 4% Chest Tube Insertion 5 9%

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


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Patient Disposition from ED Figure 29.

Figure 29 shows the breakdown of patient disposition from the ED in 2015 as compared to the historical trend. This past year, there was an increase of direct admissions and a decrease of ward admissions when compared to the past five years. There was one ED death in 2015.

4. In-Patient Care Management and Outcomes Surgical Procedures Table 5. Five-Year Trend 2011/2012 2012/2013 2013/2014 2014 2015 Total Major Trauma Patients 90 76 95 96 66 Total Patients Requiring Surgery 30 20 27 27 22 Total OR Visits 54 25 31 52 29 Total OR Hours 162 42 80 130 63 Mean (hours per case) 5.4 2.1 2.7 2.5 2.8 Mean (visits per case) 2 1 1 2 1

In 2015 22 (33%) of trauma patients went to the OR. This is higher than the 5 year average of 25%. Note the total OR hours have decreased significantly this past year as compared to 2014, and are well below the 5 year average of 95.


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Figure 30. Total Patients Requiring Surgery

Table 6. OR Data by Service

OR Data by Service - 2015

Physician Service # of Procedures Neurosurgery 6 Orthopedics 9 Pediatric General Surgery 11 Plastics 4 ENT 1

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. Figure 31. Time of Day to OR

Figure 31 compares the time patients went to the OR from 2011/2012 to 2015. In 2015, the majority of patients went to OR between 08:01 - 16:00 as compared to 16:01 - 24:00 in 2014.


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Length of Stay Statistics Figure 32. Patient LOS

Figure 32 compares the hospital admission LOS of patients from 2011/2012 to 2015. In 2015, the median LOS for all patients was 5 days - consistent with the previous 5 year average of 5 days. A majority of patients (87%) stayed between 1 and 12 days, while 13% of patients stayed between 13 and 98 days. Admitting Physician Service Analysis – 2015 Table 7.

General Surgery service appropriately continues to be the main service caring for major trauma patients. In 2015, a total of 28 patients (43%) were initially admitted to ICU. Those patients were subsequently transferred to the following:

2 patients went to Neurosurgery 9 patients went to Pediatrics 8 patients went to General Surgery 8 died in ICU 1 patient was transferred to the Foothills Spine service

Physician Service # Patients Initially

Admitted to

Service

Percent of Total

Patients Admitted n=65 (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 28 43% 2 30 179 6 3 Neurosurgery 6 9% 2 8 30 4 4 Orthopedics 2 3% 0 2 17 9 9 Pediatrics 2 3% 9 11 677 62 62 General Surgery 24 37% 8 32 156 5 4 Urology 3 5% 0 3 12 4 3


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Hospital Discharge Destination Figure 33. Discharge Destinations

Figure 33 shows that more patients went home with support services in 2015 as compared to the historical trends. Documentation of this service has improved from the trauma unit. Outcomes by Age Figure 34. Survivors

Figure 34 compares all age groups of survivors.


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Figure 35. Non-Survivors

Figure 35 shows 9 deaths in 2015. Two children less than one yr of age died from severe head injuries post MVC. One child less than one yr of age died from severe head injuries resulting from non-accidental or intentional injury. One child less than one yr of age died from drowning. 5 yr old died from severe head injuries resulting from non-accidental or intentional injury. 9 yr old died from severe head, lungs and abdominal injuries from skiing. 10 yr old died from accidental strangulation. 12 yr old died from a tracheal injury resulting from an ATV collision. 15 yr old died from severe head injuries resulting from a fall.

Outcomes by ISS Figure 36. Survivors vs Non-Survivors by ISS

Most survivors (47%, n=27) had ISS from 16 to 25. Non-survivors were in the ISS range 16-25 with 33.5% mortality rate, 26-35 with a 22% mortality rate and 36-45 with a 33.5% mortality rate, and ISS range 45+ with 11% mortality rate.


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TRISS Pre Charts for 2015 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 37. Pediatric Pre Charts include blunt and penetrating mechanisms for patients < 15 years. Pediatric AIS 2005 Coding

Generated 05/05/2016 Arrival Dates 01/01/2015 - 12/31/2015

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 + ........................ + 3 | .......................... | T + ............................. + R | ...............D.........L..... L | A 4 + ...............L....L...D.D...... D L + 4 U | .................................... | M + ...................................... + A | ......................................... | 5 + ........................................... + 5 S | ............................................. | C + ................................................ + O | .................................................. | R 6 + ..................................................... + 6 E | ....................................................... | + .......................................................... + | ............................................................ | 7 + .............L......L......................................... + 7 | ................................................................. | + ...............LL..L.L...L..L...................................... + | ...........L.L.LLLLLL...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 were three unexpected deaths and two unexpected survivor in 2015 for patients less than 15 years using the TRISS methodology. All deaths are reviewed at the Trauma Quality Management Committee to ensure appropriate care was done.


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Figure 38. Adult Pre Charts include blunt and penetrating mechanisms between 15 and 17 years. Adult Blunt (15 - 54) AIS 2005 Coding

Generated 05/05/2016 Arrival Dates 01/01/2015 - 12/31/2015

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 + ........................ D + 3 | .......................... | T + ............................. + R | ............................... | A 4 + ................................. + 4 U | .................................... | M + ...................................... + A | ......................................... | 5 + ........................................... + 5 S | ............................................. | C + ................................................ + O | .................................................. | R 6 + ..................................................... + 6 E | ....................................................... | + .......................................................... + | ............................................................ | 7 + ............L................................................. + 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 2015 using the TRISS methodology.

ach pediatric trauma program, annual report 2015 · pediatric trauma program . annual report . 2015...

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