ACH Pediatric Trauma Program, Annual Report 2014 · 2016-07-12 · ACH while further disposition is...

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ALBERTA CHILDREN’S HOSPITAL

PEDIATRIC TRAUMA PROGRAM

ANNUAL REPORT

2014

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 .................................................................................................. 5

3. Education ...................................................................................................... 8 4. Research ..................................................................................................... 11

5. Quality Assurance ....................................................................................... 13

6. Future Planning .......................................................................................... 14

APPENDICES

Appendix A Trauma Quality Indicators .......................................................... 15

Appendix B Major Trauma Statistics .............................................................. 31

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1. Introduction The Pediatric Trauma Program has had another strong and successful year. We have remained committed to implementing all of the recommendations made in the last Trauma Association of Canada Accreditation and we look forward to working with Accreditation Canada in the coming years to ensure that we continue to deliver the highest level of care to the children of Southern Alberta. 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). Ms. Sherry MacGillivray continues as our Pediatric Trauma Coordinator and the co-chair for the Pediatric Committee of TAC. Our multidisciplinary trauma team provides outstanding care. Our Trauma Team Leader (TTL) is an Emergency Physician assigned to a designated trauma shift, whose first priority is the management of patients in the trauma bay. We have a team of highly skilled, experienced nurses, all qualified through the Trauma Nursing Core Course, as well as outstanding Respiratory Therapists, who together are the backbone of the trauma team. The Trauma Surgery Team responds to every trauma activation, and works hand in hand with the TTL to guide the resuscitation in the ED and determine appropriate patient disposition. In addition, the Pediatric Intensive Care Team also responds to activations, providing their expertise in the management of critical care. Our trauma activations also include the x-ray and CT technicians and attending radiologist who strives to give finalized imaging reports within the hour. We run regular mock traumas with our entire trauma team, including the OR, to ensure the preparation of our team. The In-patient Trauma Program provides integrated care throughout the patient’s stay and through their rehabilitation process. The recent implementation of a solid organ injury protocol has standardized the management of solid organ injuries with the goal of reducing the length of hospital stay and increasing early mobilization without an increase in early or late complications. The Brain Injury and Rehabilitation Program continues to work with patients who have suffered traumatic brain injuries and a new ‘Curious About Concussion?’ clinical education session for patients and families has also been launched. Through our close relationship with the ACH Canadian Hospital Injury Reporting and Prevention Program, we strive to be a vocal advocate for injury prevention from education around sports related head injury to awareness of the life-threatening risks of ATV use. Education has always been one of the strengths of this Trauma Program, which we continue to build upon. Our trauma educators have once again provided outstanding teaching throughout the year. In 2014, 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

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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. 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. J. 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. The reporting structure has changed this past year from a fiscal year to the calendar year. This was done in preparation for submission to the National Trauma Data Bank based in the US. There are 17 patients in this report that were also reported on in the 2013-2014 report.

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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 2014 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 2014.

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 2014 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

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difficult airway. Activations are monitored and reviewed by the Trauma Committee.

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

(Emergency Physicians) looking after major trauma patients. It was created to help address gaps in documentation that were identified in Quality 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 2014 completion rate was 94%, which is an increase from last year.

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

Alberta Trauma Coordinators (ATC) 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 the fall of 2013 with the new revision released in January 2014.

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. 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

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success. We would like to extend our gratitude to the ACH Child Life Specialists for making this important program a continued success.

xii) ACH Trauma Manual

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

xiii) Liaising with Regional, Provincial and National Groups

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

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

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

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

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

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3. Education

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

• January 23, 2014 – Dr. Elaine Gilfoyle “The Trauma Team – its More

than just the ABC’s”

• February 27, 2014 – Dr. Carlos Sanchez-Glanville “Management of Blunt Thoracic Trauma in the Pediatric Population”

• April 24, 2014 – Dr. Rob Harrop “Pediatric Facial Fractures”

• May 22, 2014 – Dr. Jarret Woodmass “Compartment Syndrome of the Lower Extremity in Children”

• September 25, 2014 – Dr. Mark Gale “Pediatric Airway management in Austere Environments”

• October 16, 2014 – Dr. Andrew Ryu “Pediatric C-Spine Injuries”

• November 27, 2014 – Dr. Carolina Fermin-Risso “Urethral Trauma in Pediatrics”

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 Codes

• 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.

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

the Pediatric Human Patient Simulation Program, continues to deliver education to both regional and rural partners. These are very popular multidisciplinary educational sessions that are expected to expand even further in the future.

The following centres were visited in 2014:

March 2014 Strathmore, Black Diamond April 2014 Cardston, Fort McLeod, Sundre May 2014 Vulcan, South Calgary Health Centre June 2014 Cranbrook BC, Olds, Innisfail Sept 2014 Claresholm, Red Deer Oct 2014 Banff, Lethbridge, High River Dec 2014 Pincher Creek, Crowsnest Pass

v) Emergency 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. These sessions were very well received and will continue in the future.

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 students. 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 2014) • “Tips and Tricks for Procedural Interventions for Pediatric Patients” –

Sherry MacGillivray

ix) PEACH 2014: Pediatric Emergencies at ACH Conference (Calgary, AB – March 2014) • Pediatric Trauma Track – Dr. A. Mikrogianakis, Dr. K. Millar, Dr. R.

Ness, Dr. A. Wilmott, Sherry MacGillivray

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x) Trauma Association of Canada Annual Scientific Meeting

(Montreal, QC – April 2014) • Abbreviated Bedrest Protocol for Solid Organ Injuries – Lisette

Lockyer

xi) University of Calgary, Medical Education • Medical Student Course VI Lecture: Introduction to Pediatric Trauma

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

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

J. Guilfoyle • Emergency Medicine Resident Academic Half-Day: Pediatric

Trauma: Pitfalls and Pearls – Dr. J. Guilfoyle • PEM Fellow Academic Day: An Evidence Based Review of Severe

TBI – Dr. J. Guilfoyle

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4. Research

The following research projects were in progress or completed during 2014:

PUBLICATIONS:

1) Hagel BE, Romanow N, Morgunov N, Embree T, Couperthwaite AB,

Voaklander D, Rowe BH. Do visibility aids reduce the risk of motor-vehicle collision or hospitalization in bicyclists? Accident Analysis & Prevention 2014,65:85-96

2) Romanow N, Hagel BE, Williamson J, Rowe BH. Bicyclist head and facial injury risk in relation to helmet fit: a case-control study. Chronic Diseases and Injuries in Canada 2014;34(1):1-7

3) Russell K, Meeuwisse WH; Nettel-Aguirre A, Emery CA, Wishart J, Romanow N, Rowe BH, Goulet C, Hagel BE. Feature-specific terrain park injury risk in snowboarders: a case-control study. British Journal of Sports Medicine 2014;48:23-28 doi:10.1136/bjsports-2012-091912

4) Romanow N, Hagel BE, Nguyen M, Embree T, Rowe BH. Mountain bike terrain park injuries: an emerging cause of morbidity. International Journal of Injury Control and Safety Promotion. DOI:10.1080/17457300.2012.749918

5) 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 2014 DOI:10.1136/bjsports-2014-093487

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IN PROGRESS:

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

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

2) Mikrogianakis A, Barlow K. Can we foresee which children will have a

favorable recovery following a mild traumatic brain injury and which will have persistent post-concussion symptoms? A study to refine a clinical prediction rule, the 4C Tool.

3) 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. American Academy of Pediatrics, San Diego Oct 2014, European Congress on Emergency Medicine, Amsterdam, Holland Sept 2014

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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 2014 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 2015 year will focus on the following activities: • Continue 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 • Focusing on improving communication with all of the services impacted in

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

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

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

ACH Trauma Quality Indicators (ISS>12) 2014

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Appendix A Alberta Children’s Hospital Trauma Quality Indicators for 2014 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

2014 n = 76 71 5 2013/2014, n = 80 79 1 2012/2013, n = 62 62 0 2011/2012, n = 77 71 6 2010/2011, n = 66 61 5

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

2014 n = 12 2 10 2013/2014, n = 19 5 14 2012/2013, n = 10 5 5 2011/2012, n = 11 2 9 2010/2011, n = 6 3 3

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.

92 92

100 99

93

8 8

1

7

2010/2011 2011/2012 2012/2013 2013/2014 2014

%Yes %No

50 18

50 26

17

50 82

50 74 83

2010/2011 2011/2012 2012/2013 2013/2014 2014

%Yes %No


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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

2014 n = 30 20 10

2013/2014, n = 37 27 10

2012/2013, n = 28 19 9

2011/2012, n = 33 20 13

2010/2011, n = 35 24 11

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 a Provincial Trauma Committee indicator that is being monitored across the Province. 4. Injury time to trauma centre < 4 hours for transferred patients.

Did the patient arrive at a trauma centre < 4 hours from the time of injury? Trauma Centre is defined as ACH, FMC, U of A or Stollery Hospitals in Edmonton. As well as Red Deer, Lethbridge or Medicine Hat Hospitals. Exclusions: Out of the patient transfers, 8 patients were transferred from within Calgary, 5 from Lethbridge, 6 from Red Deer and 5 from Medicine Hat resulting in a total (n= 13) 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 2014 n = 13 5 8

2013/2014, n = 24 6 18

2012/2013, n = 13 7 6

2011/2012, n = 22 9 13

2010/2011, n = 22 5 17

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. The further progression of RAAPID (Referral, Access, Advice, Placement, Information & Destination) protocols, which started in 2011, has

69 61 68 73 67

31 39 32 27 33

2010/2011 2011/2012 2012/2013 2013/2014 2014

%Yes %No

23 41 54

23 38

77 59 46

75 62

2010/2011 2011/2012 2012/2013 2013/2014 2014

%Yes %No


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helped mobilize transport more efficiently. This has also been a priority for the Provincial Trauma Committee. Unfortunately this year there were a number of patients that were transferred from BC where RAAPID is consulted after BC Bedline attempts to accommodate their patients – this ultimately results in delays to trauma centre arrival. All patients are reviewed at the Pediatric Trauma Quality Management Committee and communication regarding means of transport is given back to RAAPID and/or the referral centre if indicated. 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 2014 n = 38 10 28

2013/2014, n = 43 13 30

2012/2013, n = 31 7 24

2011/2012, n = 42 9 33

2010/2011, n = 40 13 27

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 call 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.

33 21 23 30 26

68 79 77 70 74

2010/2011 2011/2012 2012/2013 2013/2014 2014

%Yes %No


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Resuscitative care: 6. Trauma Team Activation

Trauma Team Activation (Code 77) is the responsibility of the ED nurse answering the EMS patch phone using specific criteria that were developed by the Pediatric Trauma Committee. These include physiologic, anatomic and co-morbid factors, as well as mechanism of injury. The 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 84 (compared to an average of 139 prior to the 2013 changes). ‘Overcall’ (those not admitted) was 28%. ‘Missed call’ (those that should have had an activation according to guidelines) was 8%. The over and missed call of Code 77 patients is monitored closely by the Pediatric Trauma Coordinator and reported monthly at the Trauma Committee. 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 2014 n = 96 6 90 2013/2014, n = 93 6 87 2012/2013, n = 76 4 72 2011/2012, n = 89 7 82 2010/2011, n = 82 11 71

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 was the case for one patient this past year. Another

13 8 5 6 6

87 92 95 94 94

2010/2011 2011/2012 2012/2013 2013/2014 2014

%Yes %No

8

5

7

9 10

8

10

6 7

4

9

7

4 4 4

6 5

2

0

2 1

2 3

2

4 5

7

5 5 4

6

2

6

1

3

1 2

3

5

3 4

5

3 4 4

1

3

1

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

# of

Act

ivat

ions

Major Trauma Team Activation

2011/2012 2012/2013 2013/2014 2014


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patient was seen by an ACH pediatric emergency physician at the South Health Campus in Calgary and directly admitted to the ACH trauma unit. One was sent directly to PICU from another Calgary hospital. The remaining three were discussed at the Pediatric Trauma Quality Management Committee and should have stopped in the ED and recommendations have been made by the Committee. 8. GCS < 8 at the trauma centre (TC) with mechanical airway intervention.

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

Indicator Yes No

2014 n = 4 4 0

2013/2014, n = 5 5 0

2012/2013, n = 2 2 0

2011/2012, n = 0 0 0

2010/2011, n = 2 2 0

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

2014 n = 90 36 54

2013/2014, n = 89 35 54

2012/2013, n = 72 34 38

2011/2012, n = 83 30 53

2010/2011, n = 71 25 46

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.

100

0

100 100 100

2010/2011 2011/2012 2012/2013 2013/2014 2014

%Yes %No

35 37 47

39 40

65 63 53 61 60

2010/2011 2011/2012 2012/2013 2013/2014 2014

%Yes %No


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10. Presence of sequential neurological documentation in the ED for suspected head/spinal cord injuries

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

Indicator Yes No

2014 n = 74 54 20

2013/2014, n = 79 61 18

2012/2013, n = 59 44 15

2011/2012, n = 65 47 18

2010/2011, n = 64 44 20

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 needs to be started. Further education to continue this important clinical documentation needs to be explored. 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

2014 n = 89 3 86

2013/2014, n = 88 3 85

2012/2013, n = 67 2 65

2011/2012, n = 79 1 78

2010/2011, n = 72 2 70

These three hypothermic patients were actively rewarmed in the ED appropriately. This past year there was one patient that did not have a temperature taken in the ED.

69 72 75 77 73

31 28 25 23 27

2010/2011 2011/2012 2012/2013 2013/2014 2014

%Yes %No

3 1 3 3 3

97 99 97 97 97

2010/2011 2011/2012 2012/2013 2013/2014 2014

%Yes %No


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12. GCS <12 in the TC with a CT head performed within 4 hours of trauma centre arrival (TCA).

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

Indicator Yes No

2014 n = 4 4 0

2013/2014, n = 19 19 0

2012/2013, n = 14 14 0

2011/2012, n = 14 13 1

2010/2011, n = 11 11 0

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

2014 n = 90 44 46

2013/2014, n = 89 46 43

2012/2013, n = 72 40 32

2011/2012, n = 81 40 41

2010/2011, n = 72 35 37

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.

100

93

100 100 100

7

2010/2011 2011/2012 2012/2013 2013/2014 2014

%Yes %No

49 49 56 52 49

51 51 44 48 51

2010/2011 2011/2012 2012/2013 2013/2014 2014

%Yes %No


22

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

2014 n = 96 87 9

2013/2014, n = 93 85 8

2012/2013, n = 74 66 8

2011/2012, n = 89 82 7

2010/2011, n = 82 76 6

This past year, all 9 patients were admitted to the Pediatric service appropriately according to admission guidelines for head injuries, non-accidental trauma and burn patients. 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

2014 n = 3 3 0

2013/2014, n = 7 5 2

2012/2013, n = 3 2 1

2011/2012, n = 3 3 0

2010/2011, n = 4 4 0

93 92 89 91 91

7 8 11 9 9

2010/2011 2011/2012 2012/2013 2013/2014 2014

%Yes %No

100 100 67 71

100

33 29

2010/2011 2011/2012 2012/2013 2013/2014 2014

%Yes %No


23

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

2014 n = 96 0 96

2013/2014, n = 93 3 90

2012/2013, n = 74 0 74

2011/2012, n = 89 0 89

2010/2011, n = 82 0 82

17. Any laparotomy procedure performed.

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

Indicator Yes No

2014 n = 96 3 93

2013/2014, n = 95 2 93

2012/2013, n = 76 2 74

2011/2012, n = 90 4 86

2010/2011, n = 83 4 79

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.

3

100 100 100 97 100

2010/2011 2011/2012 2012/2013 2013/2014 2014

%Yes %No

5 4 3 2 3

95 96 97 98 97

2010/2011 2011/2012 2012/2013 2013/2014 2014

%Yes %No


24

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

2014 n = 3 3 0

2013/2014, n = 3 3 0

2012/2013, n = 4 4 0

2011/2012, n = 7 6 1

2010/2011, n = 4 3 1

Keep in mind the total n femur fractures is for ISS > 12 patients only. 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

2014 n = 1 1 0

2013/2014, n = 0 0 0

2012/2013, n = 1 1 0

2011/2012, n = 2 1 1

2010/2011, n = 1 1 0

75 86 100 100 100

25 14

2010/2011 2011/2012 2012/2013 2013/2014 2014

%Yes %No

100

100

100

0

100

50

2010/2011 2011/2012 2012/2013 2013/2014 2014

%No %Yes


25

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

2014 n = 28 1 27

2013/2014, n = 27 0 27

2012/2013, n = 20 1 19

2011/2012, n = 30 0 30

2010/2011, n = 34 0 34

This past year there was one patient that had three surgeries due to extensive abdominal injuries, where the third surgery was not planned. This case was reviewed both at the Trauma Quality Management Committee and at General Surgery teaching rounds and care was deemed appropriate. 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

2014 n = 96 2 94

2013/2014, n = 93 4 89

2012/2013, n = 74 1 73

2011/2012, n = 89 0 89

2010/2011, n = 82 0 82

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 patients’ injury was found on this survey done after the patient was reliable but outside the 48 hour timeframe. The other patients’ missed injury was found after an urgent OR and subsequent stabilization. All were reviewed at the Pediatric Trauma Quality Management Committee and recommendations were made.

5 4

100 100 95 100 96

2010/2011 2011/2012 2012/2013 2013/2014 2014

%No %Yes

1 4 2

100 100 99 96 98

2010/2011 2011/2012 2012/2013 2013/2014 2014

%Yes %No


26

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

2014 n = 1 1 0

2013/2014, n = 0 0 0

2012/2013, n = 1 0 1

2011/2012, n = 3 2 1

2010/2011, n = 0 0 0

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

2014, n = 0 0 0

2013/2014, n = 0 0 0

2012/2013, n = 0 0 0

2011/2012, n = 0 0 0

2010/2011, n = 0 0 0

0

67

0

100 33

100

0

2010/2011 2011/2012 2012/2013 2013/2014 2014

%Yes %No

0 0 0 0 0

2010/2011 2011/2012 2012/2013 2013/2014 2014

%Yes %No


27

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

2014 n = 3 3 0

2013/2014, n = 1 1 0

2012/2013, n = 3 3 0

2011/2012, n = 1 0 1

2010/2011, n = 1 1 0

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

2014 n = 1 1 0

2013/2014, n = 2 2 0

2012/2013, n = 0 0 0 2011/2012, n = 0 0 0

2010/2011, n = 1 1 0

100 100 100 100 100

2010/2011 2011/2012 2012/2013 2013/2014 2014

%Yes %No

1

100

0 0

100 100

2010/2011 2011/2012 2012/2013 2013/2014 2014

%Yes %No


28

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

2014 n = 0 0 0

2013/2014 n = 0 0 0

2012/2013 n = 0 0 0

2011/2012 n = 0 0 0

2010/2011, n = 0 0 0

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

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

Indicator Yes No

2014 n = 0 0 0

2013/2014 n = 0 0 0

2012/2013 n = 0 0 0

2011/2012 n = 1 0 1

2010/2011, n = 0 0 0

0 0 0 0 0

2010/2011 2011/2012 2012/2013 2013/2014 2014

%Yes %No

0 0 0

100

0 0

2010/2011 2011/2012 2012/2013 2013/2014 2014

%Yes %No


29

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

2014 n = 96 0 96

2013/2014, n = 93 2 91

2012/2013, n = 74 2 72

2011/2012, n = 89 1 88

2010/2011, n = 82 2 80

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

2014 n = 33 0 33

2013/2014, n = 39 0 39

2012/2013, n = 24 0 24

2011/2012, n = 36 3 33

2010/2011, n = 36 1 35

The PICU Specialized Transitional Educational Personnel (STEP) team follows patients that are transferred out of the PICU to ensure safety; this past year no patients were re-admitted to the PICU.

2 1 1 2

98 99 99 98 100

2010/2011 2011/2012 2012/2013 2013/2014 2014

%Yes %No

3

97 100 100 100 100

2010/2011 2011/2012 2012/2013 2013/2014 2014

%Yes %No


30

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

2014 n = 6 1 5

2013/2014, n = 5 3 2

2012/2013, n = 5 2 3

2011/2012, n = 4 3 1

2010/2011, n = 5 3 2

One patient died in the ACH OR within 24 hours this past year. 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

2014 n = 96 6 90

2013/2014, n = 95 5 90

2012/2013, n = 76 5 71

2011/2012, n = 90 4 86

2010/2011, n = 83 5 78

Five additional patients died after 24 hours this past year. All death cases were reviewed by the Pediatric Trauma Quality Management Committee and care was deemed appropriate.

60 75 40 60

17

40 25 60

40

83

2010/2011 2011/2012 2012/2013 2013/2014 2014

%Yes %No

6 4 7 5 6

94 96 93 95 94

2010/2011 2011/2012 2012/2013 2013/2014 2014

%Yes %No

ACH Major Trauma Statistics (ISS>12) 2014

31

APPENDIX B Major Trauma Statistics for 2014

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


32

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

2010/2011 2011/2012 2012/2013 2013/2014 2014 Total Patients

83 90 76 95 96

Males

53 63.9%

57 63.3%

48 63.1%

57 60.0%

59 61.4%

Females

30 36.1%

33 36.7%

28 36.8%

38 40.0%

37 38.5%

Total Length of Stay (LOS) (days)

1046 812 502 765 827

Median LOS

6 5 4 5 5

Mean LOS

13 9 7 8 9

Total Emergency Department (ED) LOS (hours)

328.8 397.6 318.4 402.9 390.5

Median ED LOS (hours)

4.0 3.4 3.4 3.5 4.0

Mean ED LOS (hours)

4.6 4.9 4.1 4.3 4.3

ICU Admissions

36 43.4%

37 41.1%

25 32.8%

39 41.0%

33 34.3%

Median ICU LOS (days)

2 1 2 2 2

Mean ICU LOS (days)

4 4 4 3 4

Total ICU LOS (days)

160 163 90 125 143

Median ISS

17 16 23 19 18

Mean ISS

21 21 23 24 22

Direct Admits

11 7 4 6 6

Referrals to ACH from other centres

36 43.4%

40 44.4%

31 40.8%

43 45.2%

38 39.6%

Deaths 5 6%

4 4.4%

5 6.6%

5 5.2%

6 6.3%

In 2014, 96 major trauma patients (meeting criteria for inclusion in the trauma registry)

were seen at the ACH. This volume is higher than the five-year average of 88 major trauma patients seen annually. This 2014 trauma volume represents 10.7% of all patients admitted to the ACH with injuries (n=894), which is a 0.5% decrease from last year.


33

As seen in previous years, the percentage of major trauma patients who are males (61.4%) continues to be greater than females, which is consistent with the five-year average of 62.3%.

Major trauma patients referred in from other centers represented 39.6% of the major

trauma volume for 2014. This is slightly lower than the five-year average of 42.7%. Length of stay for major trauma patients ranged between 1 and 56 days. Mean LOS of 9

days is consistent with the five-year trend of 9. Median LOS of 5 days is consistent with the five-year trend of 5.

The total ED LOS was 390.5 hours, and higher than the five-year average of 367.6

hours. Both the mean and median LOS were consistent with the five-year averages of 4.4 and 3.7 respectively.

34.3% of major trauma patients were admitted to the ICU, which is slightly lower than the

five-year average of 38.5%. Total ICU LOS was 143 days, which is higher than the five-year average of 136. The mean ICU LOS is consistent with the five-year average of 3.8 and the median is consistent at 2.

Both the mean (22) and median (18) ISS for major trauma patient from 2014 were

consistent with the five-year averages of 22.2 (mean) and 18.6 (median). A total of 6 deaths were seen in major trauma patients in 2014. This represents 6.3% of

major trauma volume, and is slightly higher than the five-year average of 5.7%.


34

Figure 1. Age and Gender Distribution for ACH Major Trauma Patients for 2014

Figure 1 shows the number of males and females for the above age groups. On average, males comprise 62.3% 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 the three pediatric patients that were treated at Calgary adult hospitals this past year. EMS protocols dictate ‘closest hospital’ when there is an airway issue or ongoing resuscitation, which was the case for two of the patients. The other patient was transferred to the PLC from ACH for 24 hour observation post head injury. All cases are reviewed by the Trauma Coordinator to deem appropriateness.

6

16

12

20

5 5

9

6

14

3

0

5

10

15

20

25

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

# of

Pat

ient

s

Age Groups

Male Female

0

1

2

3

4

5

FMC PLC RGH SHC

# of

Pat

ient

s

Year

<15 year olds Major Trauma Patients

2014


35

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 normally 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.

2010/2011 2011/2012 2012/2013 2013/2014 2014

ACH 7 8 10 3 8

FMC 24 27 22 37 24

PLC 0 0 0 0 0

RGH 0 0 0 0 0

SHC 0 0 0 0 0

0 5

10 15 20 25 30 35 40

# of

Pat

ient

s 15 to 17 year olds Major Trauma Patients


36

2. Etiology of Injuries

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

. Figure 3 shows the breakdown of the mechanism of injuries for the incidents in 2014 as compared to the historical trend. The biggest change this past year was an increase in violence related injuries.

Transport 41%

Falls 27%

Violence 6%

Other 26%

2007/2008 - 2011/2012

Transport 29%

Falls 35%

Violence 15%

Other 21%

2014

Transport 36%

Falls 31%

Violence 9%

Other 24%

2010/2011 - 2013/2014


37

Mechanism of Injury – Transportation Figure 4. Transportation Statistics

Figure 4 shows the breakdown of transportation-related injuries in 2014 as compared to the historical trend. Note: MRV is motorized recreational vehicle. A total of 28 patients (29% of major trauma patients) were involved in transportation-related incidents in 2014.

Mortality: 4% 1 patient died. ISS ranged from 13 to 57. Mean ISS was 26 and median ISS was 24.

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

Figure 5 shows a 15% decrease in transportation-related incidents from 2013/2014 to 2014.

29%

39%

26%

44%

29%

0%

10%

20%

30%

40%

50%

2010/2011 2011/2012 2012/2013 2013/2014 2014

% o

f Pat

ient

s

Years

MOI -Transportation

MVC 39%

Pedestrian 25%

Cyclist 22%

MRV 14%

2014

MVC 47%

Pedestrian 19%

Cyclist 23%

MRV 10%

Water 1%

2010/2011-2013/2014


38

Figure 6. Transportation by Age Group

Figure 6 shows the breakdown of transportation incidents by age groups in 2014 as compared to the historical trend. Significant changes to all age groups can be seen.

In 2014: Age Group <1 (n=0, 0%) No patients in this age category. Age Group 1-4 (n=5, 18%) included 2 pedestrians and 3 passengers. There was 1 death in

this age group. Age Group 5-9 (n=5, 18%) included 2 passengers, 1 pedestrian, 1 snowmobile and 1 cyclist. Age Group 10-14 (n=16, 57%) 6 passengers, 4 cyclists, 3 pedestrians and 3 ATV related

injuries. Age Group > 14 (n=2, 7%) included 1 cyclist and 1 pedestrian.

<1 0%

1 to 4 18%

5 to 9 18% 10 to

14 57%

>14 7%

2014

<1 3%

1 to 4 13%

5 to 9 32%

10 to 14

41%

>14 11%

2010/2011 - 2013/2014


39

Mechanism of Injury – Falls Figure 7. Statistics for Falls as the MOI Figure 7 shows the breakdown of falls incidents in 2014 as compared to the historical trend. There has been a significant increase in multi-level falls which includes: falls from second story windows, falls while being carried, falls off horses and falls from playground equipment.

A total of 34 patients (35% of major trauma patients) were admitted for fall-related injuries.

Mortality: 0% all patients survived. ISS ranged from 14 to 38. Mean ISS was 19 and the median ISS was 16.

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

Figure 8 shows the comparison of falls as the mechanism of injury over the past five years. This past year is above the five year average of 33%.

Multi-Level 82%

Same-Level 18%

2014

Multi-Level 75%

Same-Level 19%

Other and Unspecified

6%

2010/2011 - 2013/2014

33% 30%

37%

28%

35%

0%

5%

10%

15%

20%

25%

30%

35%

40%

2010/2011 2011/2012 2012/2013 2013/2014 2014

% o

f Pat

ient

s

MOI Falls


40

Figure 9. Falls by Age Group

Figure 9 shows the breakdown of fall incidents by age groups in 2014 as compared to the historical trend. A significant decrease is seen in the <1 yr old age group.

In 2014: Age Group <1 (n=5, 15%) All patients were multi-level falls. 4 of the patients fell while being

carried. Age Group 1-4 (n=9, 26%) included 2 multi-level falls, 5 falls out of buildings and 2 falls on

stairs. Age Group 5-9 (n=8, 24%) included 2 multi-level falls, 2 same level falls, 2 falls out of

buildings, 1 fall from a trampoline and 1 fall on stairs. Age Group 10-14 (n=10, 29%) included 5 multi-level falls and 3 falls on same level, 1 fall out

of a building and 1 fall on stairs. Age Group >14 (n=2, 6%) included 1 fall on stairs and 1 same level fall.

<1 15%

1 to 4 26%

5 to 9 24%

10 to 14 29%

>14 6%

2014

<1 26%

1 to 4 24%

5 to 9 20%

10 to 14 26%

>14 4%

2010/2011 - 2013/2014


41

Mechanism of Injury – Violence Figure 10. Violence as the MOI Figure 10 shows the breakdown of violence-related incidents in 2014 as compared to the historical trend. Note the increase in self-inflicted injuries this past year (14% = 2 patients)

A total of 14 patients (15% of major trauma patients) were admitted for violence-related injuries.

Mortality: 21% 3 patients died. ISS ranged from 13 to 38. The mean ISS was 24. The median ISS was 26.

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

Figure 11 shows the significant increase in violence related injuries over the past year – there has been a increase in non-accidental, intentional trauma and self-inflicted trauma cases.

16%

12%

8% 7%

15%

0%

5%

10%

15%

20%

2010/2011 2011/2012 2012/2013 2013/2014 2014

% o

f Pat

ient

s

MOI - Violence

Unarmed assault

7%

Self-Inflicted

14%

Other & Unspecified

65%

Assault with

object 14%

2014

Unarmed Assault

17%

Self-Inflicted

0%

Other & Unspecified

72%

Assault with

object 16%

2010/2011 - 2013/2014


42

Figure 12. Violence Incidents by Age Group

Figure 12 shows the breakdown of violence incidents by age groups in 2014 as compared to the historical trend. Note the large increase of <1 yr olds with the subsequent decrease in the 5 - 9 yr old age group.

Age Group <1 (n=6, 44%) All 6 were non-accidental or intentional injury in this age category. Age Group 1-4 (n=3, 21%) All 3 were non-accidental trauma or intentional injury in this age

category. 1 patient died in this age category. Age Group 5-9 (n=0, 0%) No patients in this age category. Age Group 10-14 (n=3, 21%) included 2 assaults with an object and 1 self-inflicted injury. 1

patient died in this age category. Age Group >14 (n=2, 14%) included 1 unarmed assault and 1 self-inflicted injury. 1 patient

died in this age category.

<1 44%

1 to 4 21%

5 to 9 0%

10 to 14 21%

>14 14%

2014

<1 32%

1 to 4 26%

5 to 9 10%

10 to 14 19%

>14 13%

2010/2011 - 2013/2014


43

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

Figure 13 shows the breakdown of other mechanism of injuries in 2014 as compared to the historical trend. There were no inhalation & ingestion or other & unspecified related injuries this year. However, there was an increase in animal related injuries and a decrease in mechanical related injuries this year. A total of 20 patients (21% of major trauma patients) were admitted for other mechanism of injuries.

Mortality: 10% 2 patients died. ISS ranged from 16 to 45. For survivors, the mean ISS was 18 and the median ISS was 16. For non-survivors, the mean ISS was 35 and median ISS was 35.

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

Figure 14 shows an 3% decrease in the number of patients whose injuries are caused by animal, burn, inhalation, submersion injury, and mechanical-related incidents when compared to the last five years.

Animal 25%

Mechanical 50%

Submersion & Drowning

15%

Fire & Explosion

10%

2014

Animal 18%

Mechanical 61%

Submersion & Drowning

14%

Inhalation & Ingestion

4%

Fire & Explosion

8%

Other & Unspecified

11%

2010/2011 - 2013/2014

28%

23%

30%

18% 21%

0%

5%

10%

15%

20%

25%

30%

35%

2010/2011 2011/2012 2012/2013 2013/2014 2014

% o

f Pat

ient

s

MOI - Other


44

Figure 15. Other Mechanism by Age Group

Figure 15 shows the breakdown of incidents involving other mechanism of injury by age groups in 2014 as compared to the historical trend. There was a significant increase in 1-4 yr olds and a decrease in <1 and 10-14 yr olds. In 2014: Age Group <1 (n=0, 0%) no patients in this age category. Age Group 1-4 (n=8, 40%) included 3 submersion injuries, 2 struck accidentally by object, 2

animal related injuries and 1 burn. There was one death in this age category. Age Group 5-9 (n=5, 25%) included 2 animal related injuries, 2 striking accidentally against

objects or persons and 1 fire/explosion injury. Age Group 10-14 (n=5, 25%) included 4 striking object or person accidentally and 1

fire/explosion injury. There was one death in this age group. Age Group >14 (n=2, 10%) included 1 animal related injury and 1 struck accidentally by

falling object.

<1 0%

1 to 4 40%

5 to 9 25%

10 to 14 25%

>14 10%

2014

<1 8%

1 to 4 27%

5 to 9 23%

10 to 14 33%

>14 9%

2010/2011 - 2013/2014


45

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 2014. Blunt injuries comprised 92% 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 2010/2011 up to 2014.

88

3 2 3 0

50

100

Blunt Penetrating Burn Other

Type of Injury - 2014 Total Pts = 96


75 81

75

90 88

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

20

40

60

80

100

2010/2011 2011/2012 2012/2013 2013/2014 2014

# o

Pati

ents

Years

Type of Injury - Five Year Trend Total Pts = 440



46

On April 1, 2012 all AHS trauma centers began capturing data on all penetrating traumas regardless of ISS in the Alberta Trauma Registry. In 2014 there were 7 penetrating traumas. Place of Injury Figure 18. Statistics for Place of Injury

Figure 18 shows where the patients were injured in 2014 which is fairly consistent with the historical trend. There was a decrease in the recreation category this past year and a significant increase in home/residential. There were no injuries that took place on a farm.

9 9 7

0

50

100

2012/2013 2013/2014 2014

# of

Pat

ient

s

Years

Penetrating Trauma All ISS

Farm 0%

Home/Res Inst 41%

Other 9%

Public Building

5%

Recreation 8%

Street 26%

Unspecified 11%

2014

Farm 5%

Home/Res Inst 30%

Other 6%

Public Building

4%

Recreation 20%

Street 27%

Unspecified 8%

2010/2011 - 2013/2014


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3. Referrals and Emergency Management Referral Patterns

Out of 440 major trauma patients from 2010/2011 to 2014, a total of 188 patients (43%) 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 30 patients (16% 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 2010/2011 2011/2012 2012/2013 2013/2014 2014 Total Region 1 - Chinook Health Region, Total = 47 Blairmore - Crowsnest Pass 1 2 3 Cardston – Municipal 1 2 1 3 1 8 Fort Macleod H.C.C. 1 1 Lethbridge Regional 7 6 7 5 5 30 Pincher Creek Municipal 1 1 2 Taber H.C.C. 1 2 3 Region 2 - Palliser Health Region, Total = 18 Bassano General 1 1 2 Brooks Health Centre 1 1 Medicine Hat Regional 3 2 2 3 5 15 Region 3 - Calgary Health Region, Total = 51 Banff - Mineral Springs 1 4 1 1 7 Black Diamond – Oilfields General 1 1 2 Calgary – Foothills 1 2 1 1 1 6 Calgary – General/Peter Lougheed 3 2 1 1 2 9 Calgary – Rockyview General 2 1 1 4 8 Calgary – South Health Campus 3 1 4 Canmore General 1 1 Claresholm General 1 1 1 3 High River General 1 2 1 4 Strathmore - Valley General 1 1 3 5 Cochrane Urgent Care 1 1 Okotoks Urgent Care 1 1


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Region 4 - David Thompson Health Region, Total = 39 Didsbury – Mountain View H.C. 1 1 2 Drumheller Regional 1 1 1 3 Hanna H.C.C. 1 1 Innisfail H.C.C. 1 1 Olds General 1 1 2 Red Deer Regional 2 4 3 4 6 19 Rocky Mountain House 1 2 3 Stettler General 2 1 3 Sundre General 1 1 1 3 Three Hills H.C.C. 1 1 2 Other Alberta Hospitals, Total = 2 University of Alberta Hospital 1 1 2 British Columbia, Total = 24 Cranbrook Regional Hospital 3 1 5 5 14 Elkford Health Centre 1 1 Fernie District Hospital 1 1 3 4 Golden & District General Hospital 1 1 Invermere District Hospital 1 1 1 3 Salmon Arm, Shuswap Hospital 1 1 Saskatchewan, Total = 4 Lloydminster General 2 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 2014 as compared to the historical trend. Note the small increase in helicopter transports for direct from the scene patients. Consistent 33% of major trauma patients arrived by private vehicle.

Figure 20. Referrals

Figure 20 shows the patients who were referred to ACH for further treatment in 2014 as compared to the historical trend. Note the increase in ground 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. Part of that process is ensuring there are no private vehicle transfers for major trauma patients. Figure 21. Ground vs Air

Ground 57%

Helicopter 10%

Private/Walk-in

33%

2014

Ground 62%

Helicopter 6%

Private/Walk-in

32%

2010/2011 - 2013/2014

Ground 68%

Helicopter 16%

Fixed-wing 16%

2014

Ground 60%

Helicopter 21%

Fixed-wing 17%

Private/Walk-in

2%

2010/2011-2013/2014


50

Ground ambulance transported 58 patients (61%) of major trauma patients in 2014, which is slightly higher than the previous fiscal year. Their ISS was a mean of 22 and median of 18. Figure 21 also shows the decrease in the use of air transport by 6% in 2014. Patients transported by air had an ISS mean of 29 and median of 26. Month and Time of Arrival Figure 22. Month of Arrival

There was an increase in major trauma patients arriving in ACH ED in all months with the exception of July, January and March in 2014 as compared to the historical trend.

0%

10%

20%

30%

40%

50%

60%

70%

2010/2011 2011/2012 2012/2013 2013/2014 2014

Ground vs Air

Ground

Air

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

Mean 10/11 - 13/14 6.0 6.8 9.5 10.3 12.0 7.8 5.8 5.5 6.0 4.0 7.8 4.8

2014 8 8 10 8 15 9 8 6 7 3 11 3

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

16.0

Comparison of ED Arrival by Month for 2014 with 2010/2011 - 2013/2014


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Figure 23. Day of Arrival

In 2014, there was an increase in major trauma patients arriving in ACH ED on Sundays, Wednesdays, and Saturdays, with the largest increase being on Wednesdays. The other days were the same volume or slightly less busy 2014 compared to the previous years. Time of Arrival Figure 24. Time of Arrival

Figure 24 shows increases in 2 of the time intervals with a significant increase in the 08:01 – 16:00 category. Note the marked decrease during 00:01-08:00. The majority of patients arrive between 16:01-24:00.

Sun Mon Tues Wed Thu Fri Sat

Mean 10/11 - 13/14 17.3 10.0 8.3 10.0 10.5 14.3 15.8

2014 18 10 7 22 9 14 16

0.0 2.0 4.0 6.0 8.0

10.0 12.0 14.0 16.0 18.0

Comparison of Arrival by Day for 2014 with 2010/2011 - 2013/2014

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

Mean 10/11 -13/14 13.5 25.3 47.3

2014 12 31 53

11%

18%

11%

0.0

10.0

20.0

30.0

40.0

50.0

60.0

Comparison of Time of Arrival for 2014 with 2010/2011 - 2013/2014


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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 2014 Table 3. Diagnostic Imaging A total of 64 patients (67% 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 73% for urgent CTs for major trauma patients.

Diagnostic Imaging CT Locations

# Patients Percent of Total Patients (n=64)

Head 46 72% Abdomen 40 63% Pelvis 40 63% Spine 14 22% Chest 28 44% Face 5 8%

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

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

Mean 10/11 - 13/14 3.0 19.3 26.3

2014 4 21 33

2.5%

8%

20%

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

Comparison of Patients Arriving Directly From the Scene for 2014 with 2010/2011 -2013/2014


53

Figure 26. Time of Day of Urgent CT

Figure 26 compares the time of urgent CTs from 2010/2011 to 2014. 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 2014, 61% (n=39) of patients who went to CT had CTs done from 16:01 to midnight. Only 8% of patients had CT’s from midnight to 8:00 AM and 31% 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 2010/2011 to 2014. In 2014 there is a significant increase in the CT’s performed on Monday and Wednesday with a decrease on all other days.

8 13

37

9

18

41

13 15

28

6

19

49

5

20

39

0

10

20

30

40

50

60

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

# of

Pat

ient

s

Time of Day

Time of Day of Urgent CT (within 6 hours of arrival, n=64)

2010/2011 2011/2012 2012/2013 2013/2014 2014

7

2

5

12

9

15

8

13

7 6 6

9 7

20

7 7

10 11

7

3

11

8

5 7 7

16

21

10 11

4

14

4

8

17

6

0

5

10

15

20

25

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

# of

Pat

ient

s

Day of the Week CT Performed

2010/2011 2011/2012 2012/2013 2013/2014 2014


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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 2014 a significant percentage 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, this past year 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 2014 Table 4. Non-operative Procedures Performed on Patients while in ACH ED

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

Gastric Tube Insertion 13 14% Foley Catheter Insertion 14 16% Intubation 10 11% Blood Product Administration 5 6% Chest Tube Insertion 1 1%

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

0

10

20

30

40

50

60

2013/2014 2014

# of

Pat

ietn

s

Year

CT within 1 hour of ED Arrival

Yes

No


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Patient Disposition from ED Figure 29.

Figure 29 shows the breakdown of patient disposition from the ED in 2014 as compared to the historical trend. This past year, there was a decrease of direct admissions and increase of ward admissions when compared to the past five years. There were no deaths in the ED in 2014 but there was one death in the OR.

4. In-Patient Care Management and Outcomes Surgical Procedures Table 5. Five-Year Trend 2010/2011 2011/2012 2012/2013 2013/2014 2014 Total Major Trauma Patients 83 90 76 95 96 Total Patients Requiring Surgery 25 30 20 27 27 Total OR Visits 40 54 25 31 52 Total OR Hours 106 162 42 80 130 Mean (hours per case) 4.2 5.4 2.1 2.7 2.5 Mean (visits per case) 1.6 2 1 1 2

In 2014 27 (28%) of trauma patients went to the OR. This is consistent with the 5 year average of 29%. Note the total OR hours have increased significantly this past year as compared to 2013/2014, and are above the 5 year average of 104. This past year more plastic surgery hours were recorded due to the type of injuries of several patients.

ICU 24%

OR/ICU 6%

OR/Ward 3%

Direct Admit

6%

Ward 60%

Died in OR 1%

2014

Died in ED 1%

ICU 24%

OR/ICU 7%

OR/Ward 4%

Direct Admit 13%

Ward 51%

2010/2011 -2013/2014


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Figure 30. Total Patients Requiring Surgery

Table 6. OR Data by Service

OR Data by Service - 2014

Physician Service # of Procedures Neurosurgery 6 Orthopedics 13 Pediatric General Surgery 6 Plastics 19 ENT 5

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. Note the large number of plastics procedures as compared to only 7 last year. Figure 31. Time of Day to OR

Figure 31 compares the time patients went to the OR from 2010/2011 to 2014. In 2014, the majority of patients went to OR between 16:01- 24:00 as compared to 08:01 – 16:00 in 2013/2014.

5

12

8

1

12

17

2

14

4 2

16

9

3

9

15

0

5

10

15

20

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

Time of Day to OR

2010/2011 2011/2012 2012/2013 2013/2014 2014

30% 33%

26% 28% 28%

0%

10%

20%

30%

40%

50%

2010/2011 2011/2012 2012/2013 2013/2014 2014

# of

Pat

ient

s

Total Patients Requiring Surgery


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Length of Stay Statistics Figure 32. Patient LOS

Figure 32 compares the hospital admission LOS of patients from 2010/2011 to 2014. In 2014, the median LOS for all patients was 5 days - consistent with the previous 5 year average of 5 days. A majority of patients (83%) stayed between 1 and 12 days, while 17% of patients stayed between 13 and 98 days. Admitting Physician Service Analysis – 2014 Table 7.

General Surgery service appropriately continues to be the main service caring for major trauma patients. In 2014, a total of 33 patients (34%) were initially admitted to ICU. Those patients were subsequently transferred to the following:

3 patients went to Neurosurgery 12 patients went to Pediatrics 12 patients went to General Surgery 5 died in ICU 1 patient was discharged home.

0%

10%

20%

30%

40%

50%

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

enti

le o

f Pat

ient

s

Number of Days

LOS by Percentile of Patients

2010/2011

2011/2012

2012/2013

2013/2014

2014

Physician Service # Patients Initially

Admitted to

Service

Percent of Total

Patients Admitted

n=96

# Patients Trans-

ferred to Service

Total Trauma Cases

per Service

Total Days

on Service

Mean LOS on Service

Median LOS on Service

ICU 33 34% 0 33 143 4 2 Neurosurgery 17 18% 3 20 59 3 1 Orthopedics 0 0% 2 2 7 3 3 Pediatrics 9 9% 13 22 258 10 6 General Surgery 34 36% 13 47 281 5 4 Urology 3 3% 1 4 11 2 2 Plastics 0 0% 1 1 37 37 37


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Hospital Discharge Destination Figure 33. Discharge Destinations

Figure 33 shows that more patients went home with support services in 2014 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.

Another Acute Care

Facility

Children's Aid/Foster

Care Died Home

Home with Support Services

Other Rehab Facility

Mean 10/11 -13/14 2 4 4.75 71.5 3.75 0 0

2014 2 4 6 62 22 0 0

0 10 20 30 40 50 60 70 80

Comparison of Discharge Destination for 2014 with 2010/2011 - 2013/2014

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

Mean 10/11 - 13/14 11.8 15.8 19.5 27.5 6.8

2014 12 21 18 32 7

0 5

10 15 20 25 30 35

Comparison of Survivors by Age Group for 2014 with 2010/2011 - 2013/2014


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Figure 35. Non-Survivors

Figure 35 shows 6 deaths in 2014. 2 yr old died from non-accidental or intentional head injuries. 3 yr old died in the OR from severe head and chest injuries resulting from an MVC. 4 yr old died from drowning needing CPR at scene. 13 yr old died from massive head, chest, spine and abdominal injuries from tobogganing. 13 yr old died from hanging needing CPR at scene. 15 yr old died from hanging needing CPR at scene.

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

Most survivors (67%, n=60) had ISS from 16 to 25. Non-survivors were in the ISS range 16-25 with 50% mortality rate, ISS 26-35 with 17% mortality rate and ISS range 36-45 with 33% mortality rate.

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

Mean 10/11 - 13/14 0.5 2.8 0.5 0.75 0.25

2014 0 3 0 2 1

0 0.5

1 1.5

2 2.5

3 3.5

Comparison of Non-Survivors by age group for 2014 with 2010/2011 - 2013/2014

5

60

16 8

1 0 3 1 2 0 0

10

20

30

40

50

60

70

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

# of

Pat

ient

s

ISS

2014

Survivors Non-Survivors


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TRISS Pre Charts for 2014 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 90 Coding

Report generated on 21/07/2015

Range From 01/01/2014 to 31/12/2014 Query is A_R_ISS

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 + .............. D + 2 I | ................ | S + ................... + E | ..................... | D 3 + ........................ + 3 | .......................... D | T + ............................. + R | ............................... | A 4 + .............................L... L D + 4 U | .................................... | M + ...................................... + A | ......................................... | 5 + ........................................... + 5 S | .............................L............... | C + ................................................ + O | .................................................. | R 6 + ..................................................... + 6 E | ....................................................... | + .......................................................... + | ...............L.....................L...................... | 7 + ...............L....L........L..........................L..... + 7 | ................................................................. | + .............L.L........LL.......L.L....L.......................... + | ............L..LLLLLL..LLL..LL.......L................................ | 8 + +---+----+----+----+----+----+----+----+----+----+----+----+----+----+----+ + 8 1 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 L = SURVIVOR(S) SHADED = Ps >= 0.50 D = DEATH(S) INJURY SEVERITY SCORE B = BOTH No Unexpected Deaths: Pediatric AIS 90 Coding Unexpected Survivors: Pediatric AIS 90 Coding

There was one unexpected survivor in 2014 for patients less than 15 years using the TRISS methodology.


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Figure 38. Adult Pre Charts include blunt and penetrating mechanisms between 15 and 17 years.

Adult Blunt (15 - 54) AIS 90 Coding

Report generated on 09/06/2015 Range From 01/01/2014 to 31/12/2014

Query is A_R_ISS

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 | ............................... | A 4 + ................................. + 4 U | .................................... | M + ...................................... + A | ......................................... | 5 + ........................................... + 5 S | ............................................. | C + ................................................ + O | .................................................. | R 6 + ........................L............................ + 6 E | ....................................................... |

+ .......................................................... + | ............................................................ |

7 + .............................................................. + 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

No Unexpected Deaths: Adult Blunt (15 - 54) AIS 90 Coding No Unexpected Survivors: Adult Blunt AIS 90 Coding (15 - 54)

There were no unexpected deaths for patients between 15 and 17 years in 2014 using the TRISS methodology.

ACH Pediatric Trauma Program, Annual Report 2014 · 2016-07-12 · ACH while further disposition is...

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