tsbc executive summary

1

Trauma Services BCA program of the Provincial Health Services Authority

Executive Summary - 2014

Stereotactic radiosurgery for intracranial arteriovenous malformations

20 OR Nurse 2011 May www.ORNurseJournal.com

Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

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Contents3 Foreword

4 Trauma Services BC

5 Why We Need An Organized Approach to Injury Management

5 Organized Trauma Care in North America

7 British Columbia Provincial Trauma System

9 Milestones in the Evolution of Organized Trauma Care in North America

10 Regional Health Authority and Partner Profiles

11 BC Trauma Registry (BCTR)

12 BC Emergency Health Services (BCEHS)

13 Map of Level 1 to 3 Trauma Facilities in British Columbia

14 Fraser Health Authority Profile

15 Interior Health Authority Profile

16 Northern Health Authority Profile

17 Vancouver Coastal Health Authority Profile

19 BC Children’s Hospital (PHSA) Profile

19 First Nations Health Authority Profile

20 Specialized Clinical Programs

21 Patient Experience

23 Trauma Services BC: The Road Ahead

24 Appendix

25 References

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ForewordThe purpose of this document is to provide decision-makers, administrators, and stakeholders with a brief introduction to Trauma Services BC. Additional historical context informs the current configuration of major trauma care, identifing important intersections with other key provider groups specifically prehospital care and transport; specialty surgical physician providers; diagnostic services; rehabilitation medicine and community services providers, to name a few. Data reporting for this major trauma population is captured through the BC Trauma Registry and prior to March 2014 submitted to CIHI for National Trauma registry annual reporting, reflecting specified outcomes metrics on major Trauma care provision across Canada. With this document, Trauma Services BC hopes to begin defining BC’s trauma care model and injury management such that a fully formed and cohesive trauma system may serve British Columbians in the years to come.

To comment on this report or to obtain an electronic copy of this report please contact Catherine Jones at [email protected]. Trauma Services BC is located at 700 - 1380 Burrard Street, Vancouver, BC, V6Z 2H3.

Contact

Catherine Jones Provincial Executive Director

David EvansMedical Director

A sincere thanks to all those have contributed their effort and time to make this document a reality. We will continue to move forward with the great work we have built upon, fostering new partnerships, while striving to achieve our goal of a truly inclusive Provincial Trauma System.

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Trauma Services BC

Trauma Services BC (TSBC) was formed in 2012 as a publicly-funded clinical program of the Provincial Health Services Authority (PHSA) to provide high-level system oversight, strategic leadership, and performance evaluation for major trauma care in BC.

TSBC evolved out of the former BC Trauma Advisory Committee which was established in 1998. A strategic council of regional trauma program leaders and pre-hospital directors created to develop and refine the organized care of major trauma in B.C. This committee succeeded in consolidating much of the infrastructure of our current trauma system, but functioned entirely in an advisory role, linked to operational activities within the regional health authorities with Ministry of Health represented as Chairperson for this group.

The recent establishment of TSBC as an entity within PHSA to facilitate provincial solutions for regionally-integrated trauma systems represents an important advance in the modernization of B.C.’s highly functional but still maturing approach to organized trauma care. Specifically, the opportunity now exists to more clearly

define the BC trauma system, to delineate functional relationships between the regional health authorities and BC Emergency Health Services, and to set more substantive performance expectations for all partners.

Although TSBC’s prime mandate is to ensure the optimal care of major trauma across B.C., it also wholly recognizes the need for strong and meaningful linkages between patient-focused systems of acute care and population-focused systems of injury management, In its 2014 strategic planning effort, TSBC confirmed it’s mission is to ensure optimal performance of the BC trauma system, with a vision of ultimately achieving, through collaboration in an expanded network of public health partnerships, the lowest burden of injury in North America for the population of British Columbia.

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Why We Need An Organized Approach to Injury ManagementThe terms trauma and injury conjure somewhat different notions.

Major trauma can be defined as serious injury resulting from a high-energy mechanism that threatens life and/or limb that requires hospitalization and specialized surgical care. Trauma systems exist to minimize preventable death due to injury by transporting the right patient to the right place in the right time, which they achieve through the seamless linkage of highly organized pre-hospital emergency medical services to a network of designated trauma centres. By delivering rapid, high-quality care, the primary objective of trauma systems is to optimize the likelihood of survival after major injury.

Injury is a term more commonly used in public health settings to connote the full spectrum of harm due to external causes, including major trauma. Fundamental to the management of injury within a population is the notion that injury is not caused by accidents, but by preventable incidents. Using broad health surveillance tools to inform strategies for prevention, policy development and built environment design, the primary objective of organized approaches to injury management is to minimize the societal burden of injury.

Serious Injury transforms lives in an instant. It happens unexpectedly and can have painful and lasting consequences. There are few things more dramatic

than the scene of a high-speed collision or a pedestrian struck down. Because all injury is needless and preventable, there is also nothing more tragic than a life permanently disabled or lost in this way.

Around the world, the leading killer of those under the age of 45 is injury. In Canada in 2009, injury resulted in over 13,000 deaths, 200,000 hospitalizations, and 3 million out-patient visits at an estimated cost of nearly $20 billion. Although it follows cancer and cardiovascular disease as the 3rd leading cause of death in Canada, more potential years of life are lost due to injury than both of these combined. In BC, there are, on average, more than 2,300 deaths, 55,000 hospitalizations, and 100,000 out of hospital visits for injury each year.

According to the Insurance Corporation of British Columbia (ICBC), 82,000 people were injured and 251 killed in motor-vehicle related crashes in BC in 2012. In the same year, WorkSafe BC identified nearly 145,000 new workplace injuries, with almost 200 fatal work-related injuries and 2.9 million days lost from work.

Death due to injury is only the very visible tip of a much larger ‘burden of injury’ iceberg. Whether measured in lives lost, number of injuries, care required, dollars spent, employment lost, or impaired quality of life, the impact of injury on the daily lives of healthy, active and productive people is enormous.

Organized Trauma Care in North America In order to appreciate the importance of a well-functioning trauma system and its inherent challenge, some understanding of how trauma systems have historically evolved is useful.

Drawing on the extensive U.S. military experience of the 1950’s and 60’s, the American College of Surgeons Committee (ACS-COT) on Trauma laid the foundation for

the development of organized systems of major trauma care in the US and, by extension, in Canada, by outlining key requirements for hospitals engaging in advanced trauma care. Based on the widely referenced Resources for the Optimal Care of the Injured Patient, ACS-COT established in 1987 a robust program of U.S. trauma centre verification and accreditation which is active today.

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The Trauma Association of Canada (TAC), formed in 1983, endorsed this U.S. model of major trauma care and trauma system development in Canada by promulgating a similar system of trauma centre verification. As such, Canada’s major trauma referral centres are designed on this model.

In 2009, TAC emphasized the importance of trauma systems over trauma hospitals by promoting accreditation at the regional level. In 2012, TAC joined with Accreditation Canada to review and update performance standards for organized trauma care in Canada and hand off the responsibility for oversight to Accreditation Canada which will inaugurate a distinction program of trauma system verification available on a voluntary basis beginning in late 2014.

Trauma Systems Save Lives

The American experience pointed the way towards treating injury using a system of care. As injury surveillance developed it became obvious that this approach was effective. According to the literature, one of the most successful traits of a trauma system is regionalization, or coordination of injury care at the regional level. Included in the regional approach to trauma care is designation of regional trauma centres of varying levels,

or capabilities (see Table 1). A systems approach reduces pre-hospitalization time, lowers the risk of death, reduces complications of the injury, shortens length of stay in hospital, decreases mortality, and improves the outcome of injured patients (Liberman, Sampalis, McKenzie, Peitzman).

For many injuries the time elapsed between your injury and treatment can be crucial to your ultimate recovery and even survival. A systems-based approach addresses this concern by allowing for efficient and timely care. Coordinated pre-hospital care allows an injured person to get to a hospital or community clinic quickly at which point stabilization and further triage can occur. This may mean that the injured person is transferred to a different facility that contains the resources and capabilities to treat the injuries with the appropriate level of care. Having different capabilities at different facilities allows for the efficient use of resources, but also for the concentration of expertise where it is needed most.

Established protocols help prevent undertriage, where an injured person is referred to a facility without the capabilities to treat the severity of their injuries which can lead to decreased outcomes for the patient, and overtriage, where an injured person is referred to a facility with capabilities beyond their needs, thus taking up bed space

Table 1. Trauma Centre Designations by Trauma Association of Canada 2011

LEVEL DESCRIPTION

Level IThese trauma centres play a leadership role in a provincial trauma system and are central in a regional trauma system. They provide Tertiary and major trauma care, including complex and unique (quaternary) trauma systems for the province. They also represent academic leadership, including trauma training and research programs usually located in large metropolitan areas.

Level II These trauma centres are required in areas without Level I trauma centres or where trauma caseload is high. They are large community based medical centres that may or may not be university affiliated.

Level III These trauma centres are required in areas without access to Level I or II trauma centres. They are typically in small urban or rural communities and are not usually university affiliated.

Level IV These trauma centres divert major trauma to Level I or II trauma centres and provide care for secondary trauma cases. They are typically located in urban centres with nearby major trauma centres. They are large community based or university affiliated medical centres.

Level V These trauma centres receive pediatric or adult cases within their catchment area if airway management is required. Otherwise they divert trauma patients to the nearest appropriate trauma centre. They are usually located in rural, small community hospitals or treatment centres.

Level Pediatric-I (P-I)These trauma centres play a central roles in provincial and regionals pediatric trauma systems. They maintain academic leadership in research and training and may serve as lead in jurisdictions of more than one Level I or II adult trauma centre. They also play an outreach role in education, advise, consultation, triage and clinical care. They are university affiliated pediatric trauma centres with full array of medical subspecialties and advanced technology and may be recognized as a “children’s hospital”.

Level Pediatric-ll (P-ll) These trauma centres typically exist as a separate administrative entity within a larger Level l or ll trauma centre. They cover a comprehensive array of medical subsspecialities and services dedicated to children and may or may not be university affiliated.

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Table 2. BC Trauma Registry Cases Within Designated Major Trauma Hospitals

FISCAL YEAR

FACILITY LEVEL 2008/09 2009/10 2010/11 2011/12 2012/13

Vancouver General Hospital 1 1662 1616 1642 1685 1573

Royal Columbian Hospital 1 1250 1324 1417 1329 1260

B.C. Children’s Hospital 1 380 368 372 413 341

Victoria General & Royal Jubilee Hospitals 2 1447 1315 1335 1262 1348

Royal Inland Hospital 2 925 858 839 732 689

Kelowna General Hospital 2 717 700 804 799 836

Lions Gate Hospital 3 769 742 728 735 756

Nanaimo Regional General Hospital 3 629 572 584 539 586

St. Paul’s Hospital 3 544 438 432 429 431

Abbotsford Regional Hospital 3 456 539 501 503 602

University Hospital of Northern BC 3 411 438 415 426 464

GRAND TOTAL 9190 8910 9069 8852 8886

Source: The BCTR Annual Report for Fiscal Year 2012/2013 (Draft)

British Columbia Provincial Trauma System

and valuable resources for those more severely injured. The systems approach best addresses these issues as well through better protocols and coordination.

What is also clear is that the trauma system must have strong leadership that coordinates care (Mullins, TAC 2011). The BC trauma system has matured over the last 30 years into an effective system; however, until recently it lacked overall, provincial leadership, despite calls for this.

Trauma Services BC fulfills this role and, along with recent restructuring of emergency health services, is perfectly positioned within PHSA to allow for coordination in all aspects of the trauma system. TSBC will allow for even more effective and efficient care of the injured person.

BC’s organized approach to major trauma care has evolved as a bottom-up integration of organizations and agencies aligned in their commitment to effective care of the major trauma patient. While 22 years of data collected in the BC Trauma Registry demonstrates that major trauma is well managed in BC, the BC trauma system is not yet a formally defined entity with terms of reference, a comprehensive operational plan and an accountable and cohesive governance structure.

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Figure 1. Government and PHSA Organizational Chart

BC Government

Ministry of Justice Ministry of Health

BC Emergency Management

BC Coroners Service

Health ServicesPublic Health Officer

BCIPLAN

BCIPPAC

BCIRPU

BCCH Trauma Program

FHA Trauma Program

VCH Trauma Program

NHA Trauma Program

IHA Trauma Program

VIHA Trauma Program

ICBC

WorkSafe BC

First Nations Health Authority

PHSA

PHSA Health Emergency Management (HEMBC)

BC Emergency Health Services

Trauma Services BC

BC Ambulance Service

Patient Transfer Network

BC Trauma Registry

Provincial specialized care centres exist for spinal cord injury, major burns, and pediatric trauma. Approximately 9,000 major trauma cases are managed annually in BC’s Trauma designated (Level I-III) hospitals.

Governance

Responsibility for the delivery of safe, effective and cost-efficient major trauma care rests independently with individual health authorities, their acute care and recovery care facilities, BC Ambulance, and the BC Patient Transfer Network. Each organization sets its own performance goals and evaluation strategy. The same is also true of related agencies such as the BC Coroners Service, Health Emergency Management BC, the BC Injury Research and Prevention Unit, WorkSafe BC, and the Insurance Corporation of BC (ICBC), all of which conduct business related to injury control. The BC Government indirectly influences the system of trauma care and injury management through the Ministry of Health by engagement of the health authorities, and the Ministry of Justice through oversight of public security, coroners’ services and provincial emergency management.

The BC trauma system comprises those de facto structures and processes supporting the organized and coordinated care across the continuum of patients with acute major trauma occurring anywhere in BC. BC Emergency Health Services, overseeing the BC Ambulance Service (BCAS), and the BC Patient Transfer Network (BCPTN), collaborates with the six BC Regional Health Authorities to provide this care.

BC has an inclusive trauma structure, meaning that all acute care hospitals and health centres across the province are part of the system and must therefore be prepared at an appropriate level of readiness to receive and redirect major trauma. A tiered system of trauma centre designation is used to specify the capacity of trauma receiving centres to stabilize patients and provide definitive care (see Table 1).

BC is served by five adult and one pediatric tertiary trauma referral centres which receive the highest level cases from around the province. There are several regional Level III centres which can provide definitive care for uncomplicated trauma, and many Level IV and V centres which serve to handle minor trauma, and receive, stabilize and redirect major trauma.

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Milestones in the Evolution of Organized Trauma Care in Canada

North America British Columbia

US National Academy of Sciences describes accidental death and disability as the neglected disease of modern

society1966

Trauma Association of Canada (TAC) established 1983

TAC develops Guidelines for Trauma Centre Accreditation 1993

Revised Trauma Association of Canada accreditation guidelines moves focus from trauma centres to regional

trauma systems2002

3rd revision of TAC Accreditation Guidelines modifying trauma facility designation scheme 2007

BC Ambulance Service established1974

BC Trauma Steering Committee (BCTSC) forms1989

Blueprint for BC trauma system tabled by the BCTSC1990

VGH Trauma Program established.8 Provincial trauma centres designated in BC1991

BC Trauma Registry (BCTR) established1992

TSBC Strategic Plan expands scope of BC ‘s trauma system to strengthen linkages to a public health framework under PHSA2014

BC Bedline transformed to BC Patient Transfer Network (BCPTN) and operationally co-located with BCASTSBC reositioned as a provincial program within PHSA

2013

BC Ministry of Health commissions 2nd report to define a provincial system of trauma care.BC Trauma Advisory Committee (BCTAC) established

1998

7 regional trauma centres designated1999

Trauma Services BC established within BC Emergency Health Services (BCEHS) under PHSA2012

VGH receives TAC accreditation as first trauma site in BC2000

BC regional trauma programs established2002

VCH first Regional trauma system accredidation in BC by TAC2005

BCAS implements air-medical ‘Autolaunch’ program2006

VIHA regional trauma system receives TAC accreditation2009

VCH regional trauma system receives TAC accreditation2010

NHA regional trauma system receives TAC accreditation2011

Trauma System in Canada begins in 70’s following the US model 1970’s

Richard Simons arrives in Vancouver and Vancouver’s system matures quickly1996

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Regional Health Authorities and Partner Profiles

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Figure 2. BC Trauma Cases by Motivation of Injury

Figure 3. BC Trauma Cases by Mechanism of Injury


Unintentional(Accidental) (92%)

Unknown (0.5%)

Intentional Self-Inflicted (2%)

Intentional Third Party (6%)

Each trauma centre participating in the BCTR Program collects comprehensive clinical data on acutely injured patients in BC that is not provided in its entirety in any other way. The BC Trauma Registry started in January 1992 at five acute care facilities in British Columbia. Today, the registry is present in eleven BC acute care facilities, including all Level I facilities (three in total), Level II facilities (three in total), and Level III facilities (five in total).The BCTR collects a detailed data set of around 300 data elements from the participating trauma centers within the following categories: Demographic, Incident, Scene, Facility, Referral or Transfer information, Injury, Complication/Co-morbidities, Interventions and Outcome. The Program has Inclusion/Exclusion Criteria that are used to identify those patients specifically targeted for comprehensive data collection and entry into the BCTR. These patients are a subset of all trauma admissions and in general reflect the more seriously injured. Data is captured on both adults and children, defined as age <= 15years.

Trauma Services BC took over the oversight of the BC Trauma Registry in 2013 when it was transferred under PHSA. This move afforded an opportunity to develop clear roles and responsibilities reflected in the newly drafted Service Agreements between BCTR and the Health Authorities that employed BCTR Registrars at each of the 11 designated trauma sites. The BCTR reports up to Trauma Services BC and is governed by the Trauma Services BC Council. The Council has representatives (including partner data stewards) from all Health Authorities and BCEHS. The BC Trauma Registry Manager is the data steward for the provincial trauma registry and coordinates with partner data stewards and the TSBC Medical Director as required.

BC Trauma Registry

The BC Trauma Registry consists of 3 main holdings:

1. Pre-Registry, PIPS (Performance Improvement and Patient Safety) data - Includes a subset of data elements from the BC Trauma Registry and is a tool primarily for Quality Improvement and Assurance.

2. BC Trauma Registry

3. Provincial Burn Registry (PBR)

The BC Trauma Registry (BCTR) is a Provincial Program responsible for the collection, maintenance, management and utilization of clinical data relating to trauma patients admitted to provincially designated Trauma Centers in BC in all six health authorities.

Fall < 1m (3.3 ft) (41%)

Other Blunt (5%)

Fall Between 1m and 6m (9%)

Vehicular Crash (31%)

Assault (4%)

Other (10%)


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BC Ambulance ServiceProfile

• Canada’s largest ambulance system.

• $241 million budget.

• 500 ground ambulances, 4 helicopters and 10 fixed wing aircraft (dedicated air

resources, incuding Autolaunch). 184 ambulance stations.

• Autolaunch helicopter dispatch guidelines.

• Critical Transport and Infant Transport teams with dedicated vehicles and

equipment.

• 3,880 paramedic and dispatch staff.

• eAmbulance mobile technology allows ambulances to be connected to

dispatch or hospitals en route.

Patient Transfer NetworkProfile

• Project began in 2011 and replaced BC Bedline in 2013.

• Coordinates transport of critical care patients across BC.

• 24,488 transfers in 2012/13

• Includes 24/7 clinical nurse and physician oversight of transport and triage for

critical RED transfers.

• Ensures better communication between physicians at sending and receiving

sites.

• Streamlines processes by providing one number to call for all transfer

requests.

• Begins repatriation process so patients and information can be transferred

back to home hospitals

BC Emergency Health Services, formerly the Emergency and Health Services Commission (EHSC), now a division of the Provincial Health Services Authority, will continue with a mandate of providing provincial ambulance and emergency health services under the Emergency and Health Services Amendment Act, 2013.

BCEHS is currently responsible for two operating entities. BC Ambulance Service provides emergency health services and ambulance services throughout the province of British Columbia. The BC Patient Transfer Network is responsible for planning and coordination of all inter-facility patient transfers.

Figure 5. BC Trauma by Pre-Hospital1 Mode of Transport

Land Ambulance (68%)

Helicopter (3%)

Other (0.3%)

Fixed Wing (0.06%)

Unknown (2%)

Private Transport (27%)


68%

27%

3%

0.06% 2% 0.3%

16%

6%3%

3%

3%

3%

3%

3%

2%2%

Top 10 Sending Hospitals (%)

Whistler D&T

Chilliwack G.

Royal Columbian

Surrey Memorial

Abbotsford R.H.

Eagle Ridge H.

Squamish General

Langley Memorial

Ridge Meadows

Mills Memorial

16%

6%3%

3%

3%

3%

3%

3%

2%2%

Top 10 Sending Hospitals (%)

Whistler D&T

Chilliwack G.

Royal Columbian

Surrey Memorial

Abbotsford R.H.

Eagle Ridge H.

Squamish General

Langley Memorial

Ridge Meadows

Mills Memorial

Figure 4. Top 10 Sending Hospitals (%)

Source: BCEHS November 2013 to November 2014 Data

35%

21%

9%

7%

4%

4%

3%3% 2%

1%

Top 10 Receiving Hospitals (%)

Vancouver General

Royal Columbian

Lions Gate

Abbotsford Regional Hospital

Victoria General

Royal Inland

OOP - Foothills Medical Centre

Kelowna General

University Hospital of Northern BC

OOP - Royal Alexandra

35%

21%

9%

7%

4%

4%

3%3% 2%

1%

Top 10 Receiving Hospitals (%)

Vancouver General

Royal Columbian

Lions Gate

Abbotsford Regional Hospital

Victoria General

Royal Inland

OOP - Foothills Medical Centre

Kelowna General

University Hospital of Northern BC

OOP - Royal Alexandra

Figure 6. Top 10 Receiving Hospitals (%)

Source: BCEHS November 2013 to November 2014 Data

BC Emergency Health Services (BCEHS)

1. from scene of injury

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Figure 3. Trauma System Facilities

Figure 7. Map of Level 1 to 3 Trauma Facilities in British Columbia

Interior

British ColumbiaHealth Authorities

Fraser

Vancouver Coastal

Island Health

Northern

Provincial Health Services Authority

Interior

British ColumbiaHealth Authorities

Fraser

Vancouver Coastal

Island Health

Northern


Level 1 Centre

Level 3 Centre

Level 2 Centre

0

3

6

9

12

15

18

# of

Cen

tres

Per

Lev

el

FHA 1 1 6 4IHA 2 5 251 VCH 1 2 1 9 VIHA 2 1 10NHA 1 3 22PHSA 1

Level 1 Level 3Level 2 Level 4 Level 5

Level 1 Level 3Level 2 Level 4 Level 5

Level 1-3 sites are represented on the map reflecting the tertiary centres caring for major trauma patient within B.C. and submitting BCTR data.

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Fraser Health Authority

35% of the population of BC

and highest rates of population

growth. Serving adult,

pediatric, and obstetrics.

Highlights

• Royal Columbian Hospital - Level 1 trauma centre• BC’s only Trauma Nurse Practitioner• Abbotsford Regional General Hospital (ARGH) - Level 3 Trauma Centre• Education of Medical Residents• Highest number of Autolaunches in BC

Fraser Health Authrority

Level 1 Centres

Level 3-5 Centres

$2.514 Billion Budget1

1.69 Million Population

Age ≤ 14 (16.4%)

Age 15-24 (14.0%)

Age 25-44 (28.0%)

Age 45-64 (27.5%)

Age 65+ (14.0%)

1. Reflects Total Health Care Budget for Health Authority

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Interior Health AuthorityVarying population density, from mid-size cities to sparse rural regions, with more seniors than provincial average.

Highlights

• Successfully participated in Accreditation Canada’s Trauma Distinction program pilot• High Acuity Response Team (HART) for critical care patient transport• Trauma destination protocols for all geographic areas of health authority• Rural Emergency Mobile Simulation Program

Level 2 Centres

Level 3-5 Centres



Age ≤ 14 (14.0%)

Age 15-24 (11.6%)

Age 25-44 (22.4%)

Age 45-64 (31.0%)

Age 65+ (21.1%)

Interior Health Authority


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Northern Health AuthorityLarge area with sparse population, more than half the land mass of BC (66%). Highest growth rate of senior population, with growth of 96% in 65+ demographic. Largest percentage of Aboriginal people in BC, 3 times more than any other BC Health Authrority. Recruitment and retention of health care professionals remains a challenge.

Highlights

• Early Fixed Wing Activation protocol expedites transport with review of the program anticipated• Annualized funding of program, and inclusion of the trauma program in NHA’s Critical Care Program• Pilot HA for the launch of the PTN program• Formation of NHA Injury Prevention Coalition• Expanded quality evaluation via expanded BC Pre-Registry Performance Improvement Patient Safety

Northern Health Authrority

Level 2 Centres

Level 3-5 Centres



Age ≤ 14 (18.4%)

Age 15-24 (14.0%)

Age 25-44 (26.3%)

Age 45-64 (28.9%)

Age 65+ (12.4%)1. Reflects Total Health Care Budget for Health Authority

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Vancouver Coastal Health AuthorityServe 25% of BC’s population, including 1 million residents of Vancouver, Richmond, the North Shore and Coast Garibaldi, Sea-to-Sky, Sunshine Coast, Powell River, Bella Bella and Bella Coola.

Highlights

• VCHA trauma leaders have worked to develop a mature, inclusive, integrated system of care for major trauma.• The VCHA trauma system scope encompasses population-level injury management.• VGH, as the Level 1 adult trauma center, provides leadership in quality program planning, academic research, education and training, for BC.• Partners in care include BCEHS, BC Children’s, BC Women’s, injury prevention, rehabilitation, health emergency management services, and public health.

Vancouver CoastalHealth Authority

Level 1 Centres

Level 3-5 Centres



Age ≤ 14 (13.0%)

Age 15-24 (12.9%)

Age 25-44 (30.9%)

Age 45-64 (28.2%)

Age 65+ (15.0%)


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Island Health Authority18.4% of population are

seniors, including highest

percentage in BC of 75+ years

old.

Highlights

• Regional Strategic Plan divided the island into four distinct geographic areas for health service delivery• Original site of the Autolaunch (rapid helicopter transport) program• Island-wide delivery of Prevent Alcohol and Risk Related Trauma in Youth (P.A.R.T.Y.) program• Forensic Nurse Examiner program being bundled in with Trauma Services

Island Health Authority

Level 2 Centres

Level 3-5 Centres



Age ≤ 14 (13.2%)

Age 15-24 (11.8%)

Age 25-44 (23.3%)

Age 45-64 (30.6%)

Age 65+ (21.1%)


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First Nations Health Authority


BCCH

BC Children’s Hospital (PHSA)BC Children’s Hospital is an agency of the Provincial Health Services Authority, providing specialized pediatric trauma services that may not be available elsewhere in the province. BC Children’s provides expert pediatric trauma care for the most seriously injured children in BC and the Yukon, aged 0-16 years.

BC Children’s Hospital first received Trauma System accreditation in 2005 by the Trauma Association of Canada as a Level 1 Pediatric Trauma Centre. This five year accreditation was renewed in July 2011.

Highlights

• Long standing Trauma simulation program for all Trauma Team member competency maintenance (multidisciplinary)• Revised and updated Pediatric Care Transport protocol

The First Nations Health Authority (FNHA) is the first province-wide health authority of its kind in Canada. In 2013, the FNHA assumed the programs, services, and responsibilities formerly handled by Health Canada’s First Nations Inuit Health Branch – Pacific Region. Our vision is to transform the health and well-being of BC’s First Nations and Aboriginal people by dramatically changing healthcare for the better.

Statistically significant health disparities exist for First Nations people in BC and across Canada. The First Nations Health Authority aims to reform the way health care is delivered to BC First Nations to close these gaps and improve health and wellbeing.

Figure 8. Map of BC Children’s Hospital

Highlights

• Trauma Services BC anticipates partnering with this new Health Authority in 2015.

Figure 9. First Nations Health Authority Signing

• Provincial Pediatric rounds provided semi-annually• Pediatric Advanced Life Support (PALS), Advanced Pediatric Life Support (APLS) run routinely

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Specialized Clinical ProgramsAt the heart of a trauma system is provision of timely and appropriate care for the most complex injuries, wherever they happen. B.C. is able to support severely injured patients with world-class expertise, and our system is dedicated to streamlining access to this expertise for all who need it.

A Provincial Strategy to Ensure Optimized Care for Complex Trauma

For traumatic injuries requiring especially advanced expertise, TSBC is establishing Provincial Working Groups (PWG’s) to broker the work outputs, provide direction and oversight that ensures we continue to deliver the best care possible to all in the most effective and efficient manner possible.

Partnership with these specialized working groups is underway and includes Major Burns, Accidental Hypothermia and spinal cord injury at the time of this report. Additional PWG’s have been proposed in the

following categories: trauma imaging, pediatric trauma, severe acute brain injury, complex orthopedic trauma, major vascular injury, severe thoracoabdominal trauma, facial reconstruction and limb re-implantation. TSBC has also partnered with PHSA telehealth to explore how these clinical specialists might continue to support and drive care beyond the walls of their tertiary or quaternary acute facilities specifically targeting consultation prior to transport or following repatriation to their home communities.

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Patient ExperienceWhat happens when someone is badly injured in B.C.?

An Illustrative Case

Brandon and his girlfriend, Jenny, are off to visit family in the Okanagan one weekend. Half way there they collide head-on with a car traveling the opposite direction that has veered into their lane. The other driver appears to have been distracted and is killed instantly. Their car flips over and Jenny is thrown while Brandon is left trapped inside, both badly hurt. Passers-by witness the crash and call 911. Fire, ambulance and police are immediately dispatched to the scene.

Layered Emergency Medical System Response

Because life-threatening injuries are likely and an air medical transport helicopter is available and within reach, a dedicated critical care paramedic crew standing by at Vancouver airport is dispatched simultaneously with a local ground ambulance. First-responders arrive within 8 minutes. Breathing with difficulty and semi-conscious with both legs broken, Brandon is extracted by fire crews using specialized equipment. The autolaunch helicopter arrives directly to the scene in 34 minutes.

Field Triage and Transport

Jenny is unconscious. The paramedics suspect a serious brain injury and determine she is the higher priority. They insert intravenous lines and a breathing tube which they are specially trained to place. Because her injuries are serious, Jenny requires care at a tertiary/quaternary high volume regional trauma centre where neurosurgeons and other specialists are promptly available. She is stabilized and transported to intensive care at the Royal Columbian Hospital as per pre-established field triage guidelines where she arrives within 75 minutes of the crash. Brandon is in shock with falling blood pressure and is taken by ambulance to the nearby hospital in Abbotsford where he is further stabilized by emergency room staff. He requires a life-saving emergency abdominal operation to control serious bleeding from a

ruptured liver which is performed by the local general surgeon trained in damage control surgery.

A Regionally Integrated System

Once stabilized, doctors suspect Brandon has an unstable spine fracture threatening his spinal cord. Some complex injuries like this can only be dealt with in one centre in the province. The BC Patient Transfer Network rapidly connects the Abbotsford surgeon to both a trauma surgeon and a spine specialist in Vancouver and all three look together on-line at the patient’s CT scan imaging. They decide Brandon needs immediate transfer to the Vancouver General Hospital. A transport physician and nurse join the conversation along with a dispatcher from the provincial Patient Transport Coordination Centre and the quickest, safest way to get Brandon transferred is organized. Another team of critical care paramedics is dispatched and two hours later Brandon arrives at VGH where a fully staffed trauma team is activated to continue his care.

The Continuum of Care

Brandon undergoes surgery to stabilize his spine. He also requires several subsequent operations by orthopedic surgeons for fractures of his pelvis and both legs, by plastic surgeons for facial fractures, and by general surgeons for his abdominal injuries. He spends 7 days on a ventilator in intensive care before being transferred to an intermediate care unit. Specialists in pain management, nutrition, occupational and physical therapy, and many others assist with his care. After 4 weeks in hospital he is transferred to the GF Strong Hospital for 5 weeks of in-patient rehabilitation under the care of dedicated physiatrists. From there he discharges home with assistance and a plan for out-patient rehabilitation and follow-up with specialists. A year later, he returns to his job as a store manager.

Jenny also has multiple injuries requiring several operations and the coordinated multidisciplinary care of many specialists over 5 months in hospital. She has, unfortunately, suffered a serious brain injury and her recovery is slow despite extensive rehabilitation.

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Ultimately, however, she returns to independent living at home.

Injury Care, Control and Prevention

Both Brandon and Jenny resume productive, healthy lives thanks to a highly coordinated and regionally integrated system of advanced trauma care. The painful

interruption in their lives and the loss of the driver’s life remain, nonetheless, tragically preventable. Fortunately, injury surveillance, control and prevention brought together in a public health framework are the focus of work by an extensive array of researchers, health advocates, policy makers and community planners working to minimize the burden of injury experience by the population of British Columbia.

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Trauma Services BC: The Road Ahead

One Provincial System

After nearly two decades of building, British Columbia’s system of trauma care is at a unique and exciting threshold. With our 6 regional health authorities served by a single provincial emergency medical system (BCAS and PTN) within PHSA, we have the opportunity to forge strong connections between the working parts, thus B.C. stands to have one of the most well-defined and highly integrated trauma systems in North America.

The Continuum of Care

A full return to function and a good quality of life after injury requires the seamless management of multiple complex issues by multidisciplinary teams from initial resuscitation and stabilization, to definitive injury management, to convalescence and rehabilitation. TSBC takes this entire process into view, striving to ensure high quality at each stage with strong communication and effective transitions in between. To this end, TSBC supports verification of its health regions within the national Trauma Distinction Program of Accreditation Canada and the Trauma Association of Canada.

Actionable System-Level Performance Reporting

We are re-thinking how to best capitalize on the power of the B.C. Trauma Registry and other data sources to truly fine-tune the performance of our trauma system. The opportunity for data sharing among the agencies and organizations that collaborate to provide effective trauma care in B.C. is unparalleled in Canada, and there

is intense focus at present on building shared data platforms that generate timely, pertinent information capable of continually directing meaningful system improvement. We envision a self-learning system where clear performance metrics describe operational processes that are linked to shared outcome objectives.

Cost Efficiency and Accountability

In seeking to assure high quality at an appropriate cost, TSBC is working to identify and enhance value in the way we manage major trauma across the province. Sound fiscal management is essential to the delivery of sustainable and equitable care. Service agreements put in place this year begin to clarify expectations between TSBC and their partner Health Authorities and to outline how we can best partner together to consolidate high-functioning trauma programs across the province.

Expanding the Scope Into Public Health

While presently focused on optimizing survival after major injury through the provision of the best patient-level trauma care possible, TSBC ultimately envisions an integrated provincial system of population-level injury management that garners for B.C. the lowest societal burden of injury in North America. While we collaborate with providers and specialty groups to develop streamlined care pathways and supportive clinical guidelines, TSBC is also beginning to build responsive partnerships with public health to guide effective prevention and shape public policy that fosters safe, active living.

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The following TSBC staff directly contributed to the creation of this report:

• Catherine Jones, Executive Director

• David Evans, Medical Director

• Jaimini Thakore, Manager, BC Trauma Registry

• Leigh Dasilva, Project Coordinator

Appendix

List of tables and figures6 Table 1 Trauma Centre Designations7 Table 2 BC Trauma Registry Within Designated Major Trauma Hospitals

8 Figure 1 Government and PHSA Organizational Chart

9 Figure 2 BC Trauma Cases by Motivation of Injury

9 Figure 3 BC Trauma Cases by Mechanism of Injury

11 Figure 4 Top 10 Sending Hospitals (%)BC Trauma by Pre-Hospital Mode of Transport

11 Figure 5 BC Trauma by Pre-Hospital Mode of Transport

11 Figure 6 Top 10 Receiving Hospitals (%)

18 Figure 7 Map of Level 1 to 3 Trauma Facilities in British Columbia

18 Figure 8 Map of BC Children’s Hospital

18 Figure 9 First Nations Health Authority Signing

AbbreviationsPHSA Provincial Health Services Authority

BCEHS BC Emergency Health Services

BCAS BC Ambulance Service

PTN Patient Transfer Network

BCTR BC Trauma Registry

RHA Regional Health Authority

TSBC Staff Contributors

• Mark Dalgarno, Content Contributor

• Trauma Services BC Council, Content Contributor

Additional Contributors

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7. MacKenzie EJ, Rivara FP, Jurkovich GJ, et al. A national evaluation of the effect of trauma center care on mortality. N Engl J Med.

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12. Peitzman AB, et al. Trauma Centre Maturation. Ann Surg, 230:87-94, 1999

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14. SMARTRISK. The Economic Burden of Injury in Canada, SMARTRISK: Toronto, 2009.

15. Trauma Association of Canada. 2011, updated 2013. Trauma Association of Canada Accreditation review of Vancouver Coastal,

BCCH, Provindence Health Authority (British Columbia Regional Trauma System).

16. Trauma Association of Canada. 2011. Trauma System Accreditation Guidelines, Fourth Revision.

17. Trauma Services BC. 2014. Strategic Plan 2014-15. Draft.

18. Trauma Services of BC. 2013. The British Columbia Trauma Registry Annual Report for the Fiscal Year 2012/2013: A Summary of

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19. Vancouver Coastal Health Authority. 2013. Online News Release: VGH to offer Canada’s first 24/7 on-site Emergency Trauma

radiology service. Accessed July 6, 2014.

20. Vancouver Island Health Authority. 2013. Overview of the Island Health Trauma System and Proposed Developments.

21. Worksafe BC. 2012 Worksafe BC 2012 Statistics.

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