2019
Northern Lights Regional Health Centre Regional Trauma Program
Annual Report
Northern Lights Regional Health Centre Trauma Report 2019
Contents Contents ...... 1 Forward ...... 3 Introduction ...... 4 1.0 Mission ...... 4 2.0 Trauma Program Members/Committee Members: ...... 5 3.0 Trauma Program Member Roles ...... 6 Trauma Medical Director ...... 6 Trauma Coordinator ...... 6 Trauma Data Analyst ...... 6 4.0 Goals of this Report ...... 7 5.0 Methodology ...... 7 6.0 Initiatives ...... 9 Education ...... 9 Accreditation ...... 9 Trauma Team Activation ...... 10 7.0 Key Points ...... 11 8.0 Major Trauma Cases and Penetrating Trauma...... 12 8.0A Major Trauma by Year, 2011-2019 ...... 13 8.0B Major Trauma by Type ...... 15 8.0C Major Trauma by Injury Severity Score ...... 17 8.1 Trauma by Location of Primary Residence ...... 20 8.2 Trauma Team Activation ...... 21 8.3 Age and Gender ...... 23 8.4 Trauma by Month of Admission ...... 25 8.5 Day of the Week ...... 26 8.6 Time of Day ...... 27 8.7 Mode of Arrival ...... 28 8.7A Walk Ins with Major Trauma ...... 28 8.7B Post ED Disposition, Regardless of ISS ...... 29 9.0 Type of Injury ...... 30 10.0 Mechanism of Injury ...... 32
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10.1 Major Trauma by Mechanism and Age ...... 33 10.2 Mechanism of Injury with Major Trauma ISS ≥12 ...... 34 10.3 Mechanism of Injury with ISS ≥12, Criteria met and TTA called ...... 35 10.4 Place of Injury ...... 36 10.5 Work Related Trauma ...... 37 11.0 Transport Related Trauma ...... 39 11.1 Mode of Transportation ...... 40 12.0 Protective Devices and Injury Prevention ...... 41 13.0 Alcohol and Injury ...... 42 14.0 Emergency Department Trauma Procedures ...... 44 14.1 Diagnostic Imaging Trauma Procedures ...... 45 14.2 Procedures Performed by EMS ...... 46 15.0 Journey of the Trauma Patient ...... 47 15.1 Patient Discharge Disposition ...... 48 15.2 Destination of Transferred Patients ED and Inpatient ...... 49 16.0 Admission Service ...... 50 16.1 ED Length of Stay by Discharge Disposition ...... 51 16.2 ED Length of Stay by ISS ...... 51 16.3 Trauma Center Inpatient Length of Stay by ISS ...... 52 17.0 Mortality Rates by ISS ...... 53 18.0 Post Transfer Complications...... 54 19.0 Performance Improvement and Patient Safety (PIPS) ...... 56 20.0 Audit Filters...... 57 Works Cited ...... 58 Figures ...... 60
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Forward
We are once again proud to present our latest Annual Trauma Report. After numerous years of preparation for the provincial accreditation, we are happy to report that our review was not only successful, but also encouraging in its recommendations. It proved a valuable mechanism for comparison with other regional centres equivalent to Northern Lights Regional Hospital. The evaluating team had insight into the challenges that rural trauma centres similar to ours face. The process also emphasized the collaboration that takes place on a provincial level. We are appreciative for the support and guidance the provincial program has provided making the success possible. With the accreditation behind us, we are moving forward with a continuation of ongoing self-evaluation finding ways to continue the improvement in our regional Trauma Program.
Dr. Brian Dufresne CCFP-EM Trauma Medical Director
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Introduction Northern Lights Regional Health Center Trauma Program Trauma is one of the leading health problems faced in the world (WHO, 2004). Approximately 16,000 Canadians will die each year from preventable trauma. Injury is the leading cause of death for Canadians ages 1-44 (Parachute Canada, n.d). Not only is there a human toll but the financial costs of injury are paramount, exceeding the cost of heart disease and stroke. Preventable injuries account for 3.5 million Emergency Room visits per year. Diligence to best practice for management of traumatic injury is essential for decreased associated mortality and morbidity. A comprehensive, concise and collaborative trauma system is imperative to achieving optimal, accessible care. The Trauma Association of Canada (TAC) has defined five levels for trauma services. Levels I and II, are the highest level of care, located in urban centers. Level I are university affiliated, this often includes but is not a defining criteria for Level II centers. Level III centres are required in areas without access to I and II facilities. They are large or medium sized, community- based medical centers that are generally not university affiliated. Levels IV, V provide trauma care to small rural areas or within urban areas. The Northern Lights Regional Health Centre (NLRHC) is a Level III trauma centre, located in the city of Fort McMurray. The NLRHC provides trauma care to the catchment population of the Regional Municipality of Wood Buffalo (RMWB) and surrounding areas. As of the RMWB, 2018 census the population in the RMWB was 111,687, with an urban population of 73,974 and rural population of 3,120. The RMWB, at 66 361 square kilometers is the second largest municipality in Canada. (Regional Municipality of Wood Buffalo, 2018). Northern Alberta is rich in key resources, which support economic growth in the region including forestry, and energy. As national and international demands for natural resources increase, the need for workers to support this expanding process follows. These workers account for a transient population who work in, but reside outside of the local area. This populous is “collectively referred to as the shadow population” (Northern Alberta Development Council). In 2018, the RMWB, reported a shadow population of 34,593. This population increases the demands on regional health and trauma systems. The NLRHC strives to deliver high quality trauma care to all injured patients.
1.0 Mission
To continuously evaluate and improve the delivery of quality trauma services in the region through: . Inter-professional care
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. Continuum of Care (pre and inter hospital, primary acute care, secondary referral, and tertiary care, including transport) . Timely Care–Right Care, Right Patient, Right Time . Best practice
2.0 Trauma Program Members/Committee Members:
Trauma Medical Director Dr. Brian Dufresne Trauma Coordinator Heidi Wright Trauma Data Analyst Kim McOuat Manager, Emergency/ICU **Jamie Atkin, Michelle Van Beek Staff Surgeon Dr. Adrian Indar ** Reflect the individual in the position in 2019
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3.0 Trauma Program Member Roles
Trauma Medical Director The Trauma Medical Director provides leadership and direction to the Regional Trauma Program. The Medical Director oversees trauma initiatives and program implementation, as well as participates in Performance Improvement and Patient Safety programs. The Medical Director leads a multidisciplinary team, which strives to provide the best possible care and outcome for trauma patients in our region.
Trauma Coordinator The Trauma Coordinator is responsible for overseeing of the Trauma Program. The Coordinator participates in development and implementation of protocols and policies in the Trauma Program. Through the Performance Improvement and Patient Safety Program completes regular chart reviews, identifies trends and opportunities for improvement in patient care. Works collaboratively with staff to achieve quality improvement and clinical education, and development of educational programming. The Coordinator interprets data and trends in patient injury and trauma care. Works collaboratively with allied health with injury prevention initiatives.
Trauma Data Analyst The data analyst is responsible for data abstraction, screening for eligible trauma cases, registry maintenance, registry data validation, quality improvement, and trauma program report generation, collecting and displaying data in chart and graph forms. The analyst works closely with the trauma coordinator, emergency department manager, and the medical director.
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4.0 Goals of this Report
. To examine major traumas with an Injury Severity Score (ISS) ≥ 12 and penetrating injuries treated at the NLRHC
. To report information about trauma patients treated, admitted to or transferred from the NLRHC, or deceased while in the facility.
. To quantify data about major traumas admitted to the NLRHC
. Increase awareness of injury in our region, highlight areas of improvement through data analysis
. To support injury prevention programs within the region
5.0 Methodology
All information and statistics collected in this report are extracted from the Alberta Trauma Registry database. As part of the American College of Surgeons Committee on Trauma (ACS CoT) and Accreditation Canada Guidelines, an accredited trauma center requires a trauma registry.
The Trauma Registry is a data collection program that when used with the Digital Innovation Report Writer (DIRW) Software, can provide data to interpret requests, and display graphs to document care trends.
Data collected includes patient demographics, mechanism of injury, information from; pre-hospital, sending hospital, trauma center emergency department and trauma center inpatient documents. Operative data, injury diagnosis, patient outcome and specific audit filters and performance indicators are also collected. Collected data is then categorized and analyzed using the DIRW software application.
There are a total of 426 unique data elements. Some elements have multiple entries. A patient qualifies for entry to the database if they meet the following criteria: . An Injury Severity Score (ISS) ≥12 admitted as an inpatient to NLRHC, or transferred to a higher level of care, or died in the ED
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. All penetrating injury as the primary mechanism of injury, regardless of ISS, with the criteria being inpatient admission to NLRHC > 24 hours and treatment in the operating room, or died in the ED
Not all admitted trauma patients are included in the trauma registry. To qualify, a patient must have an Injury Severity Score (ISS) ≥ 12 or have a penetrating mechanism and be admitted to the trauma centre for > 24 hours with a consultation from a surgeon, or receive treatment in the main operating room, or die in the emergency department of the trauma centre. All NLRHC patients who have a trauma team activation are also included in the registry.
The Injury Severity Score (ISS) is an anatomical scoring tool that provides an overall score assessing trauma severity for patients with single system or multiple system injuries. Each injury is assigned an Abbreviated Injury Scale (AIS) score and is allocated to one of six body regions (head, including cervical spine; face; chest, including thoracic spine; abdomen, including lumbar spine; extremities, including pelvis; and external). The highest AIS score in each body region is used when calculating the ISS. In 2015, the current AIS 2005-Update 2008 manual was implemented. The three most severely injured body regions have their highest score squared and added together to produce the ISS score. A higher ISS score reflects a higher severity of injuries and increased incidence of mortality.
The International Injury Scaling Committee (IISC) has a mission statement that incorporates the needs of many medical specialties dealing with trauma including epidemiology, treatment and prevention; as well, government agencies, data collection and analysis. Several objectives were identified for the IISC prior to the release of AIS 2005 (Abbreviated Injury Scale 2005) and although these objectives change as diagnosis and treatment become more advanced there are several components of severity determined by the many versions of AIS: Threat to life Mortality Amount of energy dissipated/absorbed Hospitilization and need for intensive care Length of hospital stay Treatment cost Treatment complexity Length of treatment Temporary and permanent disability Permanent impairment Quality of life
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Excluded in these numbers are individuals who died at the scene because of traumatic injury, as coroner data is not collected. The Trauma Data Analyst complies a list of trauma patients from Meditech who meet severe injury criteria. After careful scrutiny, the charts are filtered to include those with the above criteria. Patient related data is entered into the Alberta Trauma Registry. DI Report Writer is the program used to extract data for the purposes of this report.
6.0 Initiatives
Education Between January 2019 and December 2019, the following education opportunities were provided on site:
Advanced Cardiac Life Support (ACLS) – 6 Advanced Cardiac Life Support; Experienced Provider (ACLS EP) -1 Basic Life Support (BLS) – minimum five per month Pediatric Advanced Life Support (PALS) – 5 Pears – 4 Lead II – 7 Neonatal Resuscitation Program (NRP) – 6 TNCC – 1(Course Updated for New Edition)
NLRHC participated in Trauma Grand Rounds, via telehealth, from the Foothills Medical Centre in Calgary. This allows physicians, nurses and allied health access to ongoing continuing education in Trauma.
Accreditation Alberta Trauma Services, supported by Alberta Health Services (AHS) achieved Trauma Distinction through the accreditation process with Accreditation Canada. “Trauma distinction recognizes trauma systems or networks that demonstrate clinical excellence and an outstanding commitment to leadership in trauma care” (Accreditation Canada, 2018) Accreditation Canada (2018), asserts trauma distinction; enables risk mitigation and reduces high cost of errors, identifies opportunities for standardization of care, focuses on innovation and improved efficiency across the trauma network.
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The Southern Alberta Trauma System (SATS) was accredited in October 2010 by the Trauma Association of Canada (TAC). It was one of the first trauma systems to be accredited in Canada. NLRHC in collaboration with the Alberta Trauma Services (ATS) Core Leadership Team achieved accreditation as a Level III Trauma Centre and provincial trauma distinction in the fall 2019. Alberta Trauma Services is the first organization to reach Accreditation for Distinction at a provincial level in Canada. Provincially we continue to work towards meeting standards and indicators as a Trauma System and a Trauma Center, identified by Accreditation Canada. The NLRHC Trauma Program continues to actively participate in provincial learning collaborative meetings. Using these as a platform to share process and procedure and work towards a provincial standard of trauma distinction.
Trauma Team Activation The primary goal of trauma team activation criteria is to ensure resources to address the clinical needs of injured patients are immediately available. The activation protocol is based on physiologic and anatomic injury criteria. Activating the trauma team to provide immediate resuscitation to the seriously injured trauma patient is vital in providing lifesaving diagnostic and clinical interventions and the efficient functioning of the trauma center. The trauma team activation criteria include Tier 1 criteria determined by the Trauma Association of Canada, further criteria are developed by individual sites. The activation includes the immediate response of respiratory therapy, x-ray technologist, CT services, radiologist, laboratory and protective services to the Emergency Department. An additional call to the general surgeon, orthopedic surgeon and obstetrician are made at the discretion of the trauma team leader/ED physician. A member of the crisis team and the trauma coordinator respond as availability permits. The NLRHC Trauma Program adopted the Pediatric Trauma Team Activation Criteria in the fall of 2019. The pediatric trauma team activation criteria is directly resourced from current practice at the Stollery, and Alberta Children’s Hospitals. The criteria is more pertinent to injury considerations of the pediatric population, the process expedites call out for out for a pediatrician, and alerts the team of a pediatric trauma. Trauma team activations are not limited to major trauma or ISS≥12. Minor trauma (ISS≤12) often meet criteria for TTA, these cases are reviewed by site but may not be included as central site cases in the Alberta Trauma Registry data.
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7.0 Key Points
From 2018 to 2019 reported minor trauma has almost doubled in the region Major trauma has shown no significant increase from the average since 2014 Blunt trauma remains as the leading type of major trauma (ISS≥12) Severity (ISS 25-40) of major trauma decreased by 24% from 2018 61% of traumas arise from population residing within the RMWB 49% of traumas are from residents of the city of Fort McMurray Rate of TTA criteria met and called 94%, in 2018 the rate was 41% Door to CT time improved with Trauma Team Activation Male population continue to have more traumas than females in the region Of all traumas admitted to the NLRHC 34% were then transferred out to Level I or Level II centres Assaults account for the greatest mechanism of traumas in 2019 Falls continue to be the greatest mechanism of major traumas in 2019 Of admitted patients to the NLRHC, 65% were admitted to the Surgical Unit, with 30% to ICU, the remaining to Palliative Care and Pediatrics The average ED length of stay for all trauma was 5H 34minutes Patients with an ISS 16-19 had the longest median length of stay, 10days,in comparison with other ISS categories.
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8.0 Major Trauma Cases and Penetrating Trauma
Major trauma is defined by an Injury Severity Score (ISS) of ≥ 12. Minor trauma or ISS ≤11 may have TTA called if criteria is met. Qualifying penetrating trauma cases not classified as major trauma are included in this report as ISS ≤11. A significant increasing trend is noted for minor and or penetrating traumas (ISS≤11) in the region since 2016. The increase in the number of qualifying penetrating cases may be attributed to a change in the procedure for vetting charts. Major trauma in the region has stayed consistent with previous years. However the instance of minor trauma has steadily increased with a sharp increase for 2019, almost doubling from 2018.
Major Trauma (ISS ≥12) Vs. Minor Trauma (ISS≤11)
(Includes Qualifying Penetrating Trauma Cases) 2016-2019
54
29 28 26 26 27 22
14
2016 2017 2018 2019
Major Trauma Cases, ISS ≥12 Minor Trauma Cases ISS ≤11
Figure 1- Major Trauma Cases vs. Minor Trauma 2016-2019
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8.0A Major Trauma by Year, 2011-2019
In October of 2015 per Transport Alberta, the highway connecting the city of Fort McMurray to the south, and the main thoroughfare for the region was 99% completed. This was a much-anticipated advancement for the region. From 2008 to 2012, there were 2,457 accidents recorded along the 443km route; 66 people were killed. In 2012, the provincial government supported completion of the twinning project of highway 63, projected to be completed in 2016. (Bascaramurty, 2017). Years 2014-2017; the region experienced a significant decrease in industrial development and investment, resulting in decreased expansion and employment within the oil and gas industry. Decreased value of oil and gas as a resource slowed economic growth and workforce in the region. (Marksoff, 2017). On the afternoon of May 3, 2016, approximately 88,000 people were evacuated from the city of Fort McMurray and surrounding communities when a wildfire threatened the region. Residents were prevented from returning to their homes for a 4 week period, after which repopulation was phased in. It is estimated that only 73,000 people have returned to the region. (Kornik & Mertz, 2016) Since the wildfire of 2016, the region and the city of Fort McMurray has seen continued economic decline, in line with the provincial economy. In 2019 an estimated 37% of homes were rebuilt in the city. (McDermott, 2019)
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The data below represents a significant decrease in major trauma from 2014 in the region. Through years 2016-2019 a decreased however stabilized instance of major trauma is noted. The Abbreviated Injury Scale 2005 (AIS, 2005) was implemented in Alberta in 2015. This new level of diagnostic detail altered the qualification for major injury; as a result, NLRHC experienced a reduced number of cases with high Injury Severity Score (ISS). Major trauma in the region remains relatively consistent, and reflects only a slight increase since 2018.
Major Trauma (ISS≥12) by Year 2011-2019 2015* AIS updated resulting in a drop in qualifying cases
65
49 40 37 33 26 26 27 28
2011 2012 2013 2014 2015* 2016 2017 2018 2019
Figure 2-Major Trauma by Year, 2011-2019
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8.0B Major Trauma by Type
Injury types are defined by the National Trauma Registry of Canada. Blunt injury: Refers to the type of injury reflecting the cause of injury (i.e. motor vehicle collision, a blow to the head). Blunt injury may include deep lacerations caused by impact but does not include any injury in which a missile or cutting instrument enters the body. Penetrating injury: Refers to any injury caused by a missile entering the body, human or animal bites, machinery that also include power or non-powered hand tools. Burns: Refer to injuries to tissues caused by chemicals, radiation, electricity, heat or friction. Below is reflection of type of injury in the region for 2019. Major trauma patients (ISS ≥ 12) presenting with blunt injury are consistently higher than penetrating injury and burns. There is an overall increase of blunt and penetrating trauma in 2019 from 2016-2018; where blunt trauma accounted for 87%, 9% penetrating trauma. Burn trauma was significantly diminished from 4% burn trauma 2016- 2018.
Major Trauma (ISS≥12) by Injury Type
89% 25
11% 3 0% 0
BLUNT PENETRATING BURN
Figure 3- Major Trauma (ISS≥12) by Injury Type
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The following data represents the number and type of traumatic injury by ISS score. In our region there were no injuries above the ISS score of 55 for 2019, further there were no burn injuries that exceeded an ISS score of 11.
Type of Injury by ISS Range
10
8
5
2 1 1 1 0 0 0
ISS 12-16 17-25 26-35 36-45 46-55
Blunt Penetrating
Figure 4- Type of Injury by ISS Range
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8.0C Major Trauma by Injury Severity Score
Injury Severity Score (ISS) is an internationally recognized scoring system developed to assign a level of severity to an injury. As an extension of the Abbreviated Injury Scale (AIS), it is the sum of the squares of the highest AIS score in each of the three most severely injured body regions. The ISS is 1 (minor) to 75 (major) with a higher score indicating increased severity and mortality. Entry into the trauma registry requires a classification as a major trauma or having an ISS score greater than or equal to 12. Penetrating injuries with specific criteria are entered into the provincial trauma registry but if they do not have an ISS ≥ 12 , they are not reported as major trauma. The following data represents a summation of all major trauma in the region by ISS score for 2019. Major trauma with ISS 25-40 increased 24% from 2016- 2018. However, major trauma with ISS 16-24 decreased by 30%. Major traumas with ISS 50-74 and 12-15 remain consistent with previous data.
Major Trauma (ISS ≥12) by ISS
ISS 25-40 ISS 50-74 12 1 43% 3%
ISS 12-15 ISS 12-15 10 ISS 16-24 36% ISS 16-24 ISS 25-40 5 ISS 50-74 18% Figure 5- Major Trauma by ISS
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The following graph represents the average ISS of all trauma patients years 2012-2019. A significant decrease in patient numbers is noted for years 2015- 2016 from previous years, this correlates with a slowing of economic growth in the region. However we see a steady increase of patients from years 2017-2019, with a marked increase from 2018 to 2019. Average ISS for 2019 remains consistent with 2017 and 2018. The average total ISS for all patients 2012-2019 is 10.75.
Average ISS of Trauma Patients 2012-2019
112 112 100
82
61 56 48 40 15 10 11 12 12 11 10 5
2012 2013 2014 2015 2016 2017 2018 2019
Average ISS # of Patients
Figure 6-Average ISS of Trauma Patients 2012-2019
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The data presented in the following graph, represents the average ISS score of Major Traumas vs the total number of trauma patients. Through the years 2012 to 2019 the average ISS score of the Major trauma patients has remained relatively stable with a slight decrease in scoring years 2015-2019, as anticipated with the implementation of the AIS 2005 in 2015. The average ISS of major trauma has increased from 19 (2018) to 22 (2019), while the number of major trauma patients has only increased by 1.
Comparison of Average ISS of Major Trauma (ISS≥12) and Number of Major Trauma Patients 2012-2019
65
49 40 33 26 26 27 28 21 23 22 20 19 20 18 19
2012 2013 2014 2015* 2016 2017 2018 2019
Average ISS of Major Traumas # of Patients
Figure 7- Comparison of Average ISS of Major Trauma and Number of Major Trauma Patients 2012-2019
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8.1 Trauma by Location of Primary Residence
The volume of trauma patients presenting to the NLRHC from Fort McMurray, the Regional Municipality of Wood Buffalo, other areas within Alberta, and beyond provincial borders is represented in the data below. This is an important reflection of the resources utilized by non-residents of the community, further substantiating the varying population of Fort McMurray due to oil and gas employment/employees. Only 61% of traumas involve population within the RMWB. Communities in the RMWB include; the city of Fort McMurray, Anzac, Conklin, Draper, Fort Chipewyan, Fort Fitzgerald, Fort McKay, Gregoire Lake Estates, Janvier, and Saprae Creek Estates.
Trauma Cases by Location of Primary Residence
Other Province 14 17%
Fort McMurray 40 Other Alberta 49% 18 22%
RMWB 10 12% Figure 8 - Trauma by Location of Primary Residence
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8.2 Trauma Team Activation
Below is a comparison of Trauma Team Activation (TTA) data years 2018 and 2019. Accreditation Canada requires a 90% compliance with Trauma Team Activation. The trauma program has worked to increase education and awareness of criteria for TTA. The trauma program has been working with frontline nursing and physicians to improve compliance and reach threshold. Trauma team activation greatly improved in 2019, surpassing the 90% Accreditation Canada threshold.
Trauma Team Activation - 2018
Criteria Met and TTA Not Criteria Met Called and TTA Called 10 7 59% 41%
Figure 9- Trauma Team Activation – 2018
Trauma Team Activation - 2019
Criteria Met Criteria Met and TTA Called and TTA Not 30 Called 94% 2 6%
Figure 10- Trauma Team Activations 2019
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The following data represents a comparison of time to computed tomography (CT) when a TTA occurs and time to CT when the trauma team is not activated. It is apparent that a greater percentage of patients have a CT performed within one hour of arrival when a TTA is called. This is consistent with 2016-2018 data.
Trauma Team Activation and Time to CT (Patients who met TTA criteria and had CT done.)
52% 11
38% 8 Patients to CT ≤ 1 hour Patients to CT > 1 hour
5% 5% 1 1
TTA NOT CALLED TTA CALLED
Figure 11- Trauma Team Activations and Time to CT 2019 *This data excludes patients who did not meet TTA criteria and patients who, if they met criteria did not require a CT scan
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8.3 Age and Gender
According to Statistics Canada (2010), males are most likely to be injured in comparison to females. The chart below represents all trauma regardless of ISS for 2019, and average age represented by each gender. Males continue to have a higher injury rate than females in the region. In 2016-2018 male injury accounted for 81% overall. The average age of injured males is lower than previous data, in 2016-2018 the male average age was 39.5 and female 38.7.
Gender and Age regardless of ISS
77% 63
36
23 23% 19
NUMBER OF MALES VS. FEMALES AVERAGE AGE
Male Female
Figure 11- Gender and Average Age 2019
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As evidenced by the following data, the NLRHC has the youngest age for major trauma cases in Alberta excluding the pediatric centres. The median provincial age for major trauma cases in Alberta is 54years.
Median Age by Site, Major Trauma Cases
70 57 59 59 58 60 53 52 55 50 42 40 30 20 10 8 10 0
Median Age for Alberta
Figure 12 - Median Age by Site, Major Trauma Cases
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8.4 Trauma by Month of Admission
According to Statistics Canada (2010), nationally, the likelihood of injury correlates with seasonal change. Furthermore, the incidence of injury is slightly higher in summer months. However our region saw a decrease in trauma in July with peak months of May and September. March and December saw the lowest incidence of trauma admissions for the region. The graph below demonstrates the trend of total trauma patients by admission month for 2019.
Trauma by Admission Month
9 9 8 8 8 7 6 6 6 6 5 4
JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC
Figure 12- Trauma by Admission Month
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8.5 Day of the Week
Incidence of trauma correlates with days of the week. Below is a comparison of all trauma versus major trauma by day of the week for 2019. A noted trend displays a decreased incidence of trauma early to midweek trending up to peak Friday. Interestingly trauma decreased on Saturdays to peak again on Sundays.
Trauma by Admission Day of the Week
19 19
12 10 10
6 6
MON TUE WED THU FRI SAT SUN
Figure 13- Trauma by Admission Day of the Week
Major Trauma by Admisson Day of the Week
9
7
4 4
2 1 1
MON TUE WED THU FRI SAT SUN
Figure 13- Major Trauma by Admission Day of the Week
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8.6 Time of Day
The graphs below show a comparison of all trauma and major trauma by time of day presenting to the NLRHC. As evidenced the incidence of trauma is greater in the morning hours defined as (0800-1159). This is changed from 2016-2018 where the greatest instance of major trauma presented to the ED mid-day defined as (1200-1559).
Time of Day Qualifying Patients Presented to ED 20 18 18 16 14 14 12 13 12 10 11 10 8 6 4 4 2 0 00:00-03:59 04:00-07:59 08:00-11:59 12:00-15:59 16:00-19:59 20:00-23:59 DIRECT ADMIT
Figure 14-Time of Day Qualifying Patients Presented to ED
Major Trauma by Time of Day Presenting to ED 10 8 6 8 4 5 5 5 2 3 2 0 00:00-03:59 04:00-07:59 08:00-11:59 12:00-15:59 16:00-19:59 20:00-23:59
Figure 15 - Major Trauma by Time of Day 2016-2018
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8.7 Mode of Arrival
The figure below illustrates the means by which patients arrived to the NLRHC post trauma. Compared to 2016-2018, there were no trauma arrivals unknown/other, or by police vehicle. Ground transport continues to be the most common mode of arrival to the NLRHC.
Mode of Arrival All Qualifying Patients
51
25
4 2
GROUND WALK-IN FIXED-WING HELICOPTER
Figure 16 - Mode of Arrival All Qualifying Patients
8.7A Walk Ins with Major Trauma
In years 2016-2018, 32% of walk in trauma patients were identified as major trauma. For 2019 only 8 patients were walk in traumas with an ISS ≥12. There were no eligible walk in traumas that met the TTA criteria. Continued emphasis on identification of TTA at triage is practiced on site. There were no major trauma’s that arrived as walk in’s or private vehicle.
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8.7B Post ED Disposition, Regardless of ISS
Data in the graph below demonstrates patient destination after treatment in the Emergency Department. Of all traumas in 2019 only 50% of trauma patients were admitted to an inpatient unit or the OR at the NLRHC, 34% of trauma patients are transferred to a higher level or specialized care. In 2016-2018, 66% of trauma patients were admitted to the NLRHC with 33% transferred to a higher level of care.
Post ED Disposition, Regardless of ISS
34% 30 28 28% 25 23
20 15% 15 12 11% 11% 10 9 9
1% 5 0% 1 0 0 LEVEL I OR II FLOOR HOME OR ICU AMA EXPIRED (UAH OR RAH)
Figure 17-Post ED Disposition, Regardless of ISS
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9.0 Type of Injury
Trauma and injury are of the leading health problems in the world today. Thousands of Canadians suffer from preventable injuries each year. According to the World Health Organization, “Injuries–resulting from traffic collisions, drowning, poisoning, falls or burns - and violence - from assault , self-inflicted violence or acts of war kill more than five million people worldwide annually and cause harm to millions more. They account for 9% of global mortality, and are a threat to health in every country of the world. For every death, it is estimated that there are dozens of hospitalizations, hundreds of emergency department visits and thousands of doctors’ appointments. A large proportion of people surviving their injuries incurs temporary or permanent disabilities.” (World Health Organization, 2018). According to Alberta Health Services, in 2016 alone “1,204 Albertans died from injury, 31,449 required hospitalization and 490,769 were treated in Emergency departments” (Alberta Health: Interactive Data Applications 2018, as cited in Alberta Health Services, 2019). Injury in Alberta has a significant financial impact, in “2004, injuries cost Albertans $2.94 billion in direct and indirect costs”, further “costs to a seriously injured individual and his or her family are immeasurable” (Alberta Health Services, 2019). Collection and analysis of injury and trauma data, is imperative to supporting regional, provincial and federal injury prevention initiatives.
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Below represents the distribution of injury type for all qualifying trauma patients. Trauma patients presenting with blunt injury (59%) are higher than penetrating injury (39%). Burn injuries are significantly lower, representing 2% of trauma in the region, consistent with 3% for 201-2018. In 2016-2018, blunt injury accounted for 53% of trauma and penetrating injury accounted for 44% of qualifying trauma.
Type of Injury, All Qualifying Trauma Patients
Blunt Penetrating Blunt 48 32 Penetrating 59% 39% Burn
Burn 2 2% Figure 18- Type of Injury, All Qualifying Trauma Patients
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10.0 Mechanism of Injury
Transport: Any accident involving a device designed primarily for, or being used at the time primarily for, conveying persons or goods from one place to another. Assault: Injuries inflicted by another person with intent to injure or kill, by any means. Falls: Includes fall on same level; while being carried or supported; from, out or through a building or structure; jumping or diving into water; etc. Other: Any injury sustained by neither transport related means, assault, or falls. I.e. suffocation, drowning, burns, etc. Below is a comparison of 2019 versus 2016, 2017 and 2018. Penetrating injury for 2019 is significantly decreased from 2016-2018. Assaults represent the highest mechanism of injury, where gunshots, pedestrian, bicycle injury and burns represent the lowest reported mechanism of injury for 2019.
Mechanism of Injury 2016, 2017 and 2018 Vs. 2019 60 37%
50
40
30
15% 14% 23% 20 21% 16% 17% 10% 10%
10 9% 5% 3% 3% 3% 4% 2% 2% 2% 2% 1% 0% 1% 0
2016, 2017, 2018 2019
Figure 19- Mechanism of Injury 2016, 2017, and 2018 vs 2019
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10.1 Major Trauma by Mechanism and Age
In the RMWB the age groups most affected by major trauma in 2019 include ranges 16-29 and 30-44. There is a decrease in the instance of trauma for patients 45-59 years from 2016-208 data.
Major Trauma by Mechanism and Age Ranges
3
2 2 2
5 1 4 4 1 2 1 1 0-15 YRS 16-29 YRS 30-44 YRS 45-59 YRS 60-74 YRS 75+ YRS
Transport Falls Assault Other *
Figure 20- Major Trauma by Mechanism and Age Ranges
Transport includes: all motor vehicles, motorcycles
Assaults include: physical assault with or without a weapon
Other Includes: one self-harm by strangulation, and one by gun, one by unknown cause of injury
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10.2 Mechanism of Injury with Major Trauma ISS ≥12
The following graph demonstrates the frequency of type of mechanism of injury in major trauma. As evidenced, falls and MVC’s account for the bulk of trauma seen in the region, followed by assaults. Blunt major trauma has decreased from 2016-2019 data, where it was the third highest mechanism of injury.
Mechanism of Injury with Major Trauma
9
7 6
3
1 1 1
FALL MVC ASSAULT MOTORCYCLE BLUNT GUN UNKNOWN
Figure 21- Mechanism of Injury with Major Trauma
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10.3 Mechanism of Injury with ISS ≥12, Criteria met and TTA called
The following data represents the occurrence of specific mechanism of injury with appropriate TTA. Motor vehicle collisions account for 55% of TTA’s. This demonstrates an increase from 21% years 2016-2018. In 2019 trauma team activation due to falls, assault, motorcycle and gunshot injury occur in the region at a rate of 10%.
Mechanism of Injury with ISS ≥12 vs. Criteria Met and TTA Called
9
7 6 5 ISS≥12 Criteria Met and TTA Called 3
1 1 1 1 1 1 1 0 0
FALL MVC ASSAULT MOTORCYCLE BLUNT* GUN UNKNOWN
Figure 22- Mechanism of Injury with ISS≥12 vs. Criteria Met and TTA Called
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10.4 Place of Injury
Injuries occur in many locations. “For seniors, everyday activities like household chores (27%) and walking (28%) accounted for over half of their injuries. Not surprisingly, work injuries were highest in the population of working-age adults, accounting for about 18% of all their injuries. Other research has found that one- third of all on-the-job injuries occurred among workers in trades, transport and equipment operation” (Statistics Canada, 2010). The following chart represents the occurrence of major trauma by place and mechanism of injury. In 2019 the most common mechanism of injury for major trauma involved a motorized vehicle, defined as a car, truck, motorcycle, or all- terrain vehicle. “Other” locations typically are off road transportation involving dirt bikes and four wheeled all –terrain vehicles. The majority of fall related, blunt trauma and assault occur within the home.
Major Trauma by Place and Mechanism of Injury
1 6 3 1 1 1 5 4 3 1 1 1 MVC FALLS ASSAULT BLUNT PENETRATING UNKNOWN MOTORCYCLE
Home Street/Hwy Trade/Service Residential Other
Figure 23- Major Trauma by Place and Mechanism of Injury
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10.5 Work Related Trauma
From 2016 through 2018, the majority of work related trauma was indicated in the 30-39 year demographic, however for 2019 work related trauma was more prevalent in 40-49 year demographic.
Work-related Trauma by Age, Regardless of ISS
5
2 2
0 1
20-29 YRS 30-39 YRS 40-49 YRS 50-59 YRS 60+ YRS
Figure 24- Work-related Trauma by Age, Regardless of ISS
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As indicated in the following data 40% of work related traumatic injury is a result of penetrating trauma. Comparatively 2016-2018 data shows penetrating trauma to account for 38% of all work related trauma. Note all penetrating injuries had a low ISS score (ISS ≤12).
Work-related Trauma by Mechanism of Injury
Blunt Biting 2 1 20% 10%
Penetrating Fall 4 3 40% 30%
Figure 25- Work-related Trauma by Mechanism of Injury
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11.0 Transport Related Trauma
Forms of transport include passenger vehicle, light truck, heavy truck, motorcycle, all-terrain vehicles, snowmobiles and other. According to the Injury Prevention Center (2019), “motor vehicle collisions are among the most deadly, costly, and preventable sources of injury in Alberta”. Further, from 2011-2015 motor vehicle collisions are the third leading cause of provincial injury related deaths and responsible for 309 deaths, 2,493 admissions to hospital, and 27,853 emergency visits across the province (Injury Prevention Center, 2019). Collisions involving motorcycles accounted for “377 hospital admissions and 22 deaths” from 2011-2015 (Injury Prevention Center, 2019).
All-terrain vehicles (ATV’s) are involved in a significant amount of traumatic injury in the province. According to the Injury Prevention Center (2019), between 2002 and 2013, provincially there were 185 ATV related deaths. The financial impact of ATV related trauma has cost the province $16 million dollars a year in direct healthcare costs (Injury Prevention Center).
“ATVs cause more permanent disabilities and death (commonly called “catastrophic injuries”) than most other sport or recreational activities.” (Parachute, n.d)
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11.1 Mode of Transportation
Passenger vehicle mode of transportation, as evidenced in the data below accounts for the greatest amount (38%) of transport related injuries. The incidence of light truck related trauma saw the most significant decrease in 2019. This decline is closely followed by motorcycle related trauma. There was a rise in snowmobile related trauma in the RMWB for 2019.
Mode of Transportation Resulting in Injury 2016-18 vs 2019 28% 8 24% 7 21% 38% 6 6 14% 25% 4 4 19% 3 7% 13% 6% 2 3% 2 3% 1 0% 1 1 0% 0 0
ATV LIGHT TRUCK MOTORCYCLE PASSENGER HEAVY TRUCK SNOWMOBILE OTHER VEHICLE
2016-2018 2019
Figure 26- Mode of Transportation Resulting in Injury 2016-18 vs 2019
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12.0 Protective Devices and Injury Prevention
The World Health Organization research has provided clear evidence that certain interventions can prevent injuries, “including:
seat-belts, helmets and enforced blood alcohol limits to prevent road traffic injuries; child-resistant containers to prevent poisonings; home hazard modification to prevent falls among the elderly; pool fencing to reduce the risk of drowning.” (World Health Organization, 2018)
Of all major trauma involving transportation in 2019, 60% of patients reported use of a safety device. This is an increase from 2016-2018 data where only 53% of trauma patients reported safety device use. Safety devices include seatbelts, helmets, airbags, and protective gear.
Major Trauma in Transportation, Restraint/Protective Device
Not Documented 2 20%
No Restraint/Protective Device 2 20% Restraint/Protective Device Used 6 60%
Figure 27- Major Trauma in Transportation, Restraint/Protective Device
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13.0 Alcohol and Injury
“Persons under the influence of alcohol are more likely to be injured and are more likely to sustain a serious injury” (Injury Prevention Center, 2019). Further, “in Alberta, 3.1% of drivers involved in injury crashes were judged to have consumed alcohol prior to the crash, compared to 19.8% of drivers involved in fatal collisions” (Injury Prevention Center, 2019). Alcohol impairment also contributes to trauma and trauma related death with all-terrain vehicles, from 2002-2013, 51% of ATV drivers killed were over the legal blood alcohol limit of (0.05) (Injury Prevention Center, 2019). The Injury Prevention Center (2019), further assert alcohol is a factor in fatality related snowmobile incidents, suicidal behavior and spousal abuse injuries. The legal alcohol limit is 11mmol/L (equivalent to 0.05 on a breathalyzer test). In 2019, 26 patients had ETOH greater than or equal to 11mmol/L. Blunt and penetrating injuries were equally split at 13 patients. Penetrating injuries involving ETOH (assault) were predominant at 12/13 = 92%. The following graph represents the occurrence of positive and negative ETOH (ethyl alcohol) levels in all trauma patients regardless of injury level.
ETOH Levels, All Trauma Patients Tested Positive ≥ Tested Positive < 11 mmol/L 11 mmol/L 32% 5%
Not Tested Tested Negative 44% for ETOH 19%
Figure 28- ETOH Levels, All Trauma Patients
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In the following graph, the data represents the occurrence of all major trauma’s (ISS≥12) with ETOH testing and respective ETOH results. In 2019 38% of patients tested positive ≥11mmol/L, this is an increase from 2016-2018 where only 22% of patients were positive for ETOH ≥11mmol/L.
Major Trauma (ISS≥12) with ETOH Levels
10 9 8
1
NOT TESTED TESTED NEGATIVE TESTED POSITIVE ≥11 TESTED POSTITIVE < 11 MMOL/L MMOL/L
Figure 29- Major Trauma (ISS>12) with ETOH Levels
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14.0 Emergency Department Trauma Procedures
The Emergency department is equipped to manage immediate trauma care. The following graph shows the frequency of most commonly performed procedures on trauma patients in the Emergency Department for 2019 including CT.
Procedures on Trauma Patients in the ED
RESUSCITATION HEART 1 REPAIR VENTRICLE 1 REDUCTION PHALANX HAND 1 REDUCTION FEMUR 1 INSPECTION LARYNX 1 IMMOBILIZE - RADIUS AND ULNA WITH SKELETAL TRACTION 1 SPLINT FOOT 1 SPLINT RIBS 1 SPLINT KNEE 1 HYPOTHERMY 1 LOCAL ANESTHESIA SPINAL CANAL AND MENINGES 1 STIMULATE HEART, SHOCK 2 SPLINT FEMUR 2 DEBRIDEMENT SOFT TISSUE 2 VAD VENA CAVA 4 IMMOBILIZE SPINE 5 DRAIN PLEURA 6 VENTILATION PO AND POSITIVE PRESSURE 7 INTRA-ARTERIAL CATHETER 7 VENTILATION INVASIVE AND MANUAL ASSIST 8 INTUBATION STOMACH 10 DRAIN URINARY BLADDER 23 TRANSFUSION BLOOD, BLOOD PRODUCTS 28 SUTURE SKIN 35 INTRAVENOUS CATHETER 65 CT 92 0 20 40 60 80 100
Figure 30- Procedures on Trauma Patients in the ED
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14.1 Diagnostic Imaging Trauma Procedures
The following graph demonstrates the type and frequency of computed tomography (CT) indicated for major trauma patients. Of all CT procedures, CT of the head accounted for 34% of CT procedures. CT of the spine and CT of the chest, abdomen and pelvis were most frequently used following CT of the head. This is consistent with data from 2016-2018. There were no MRI procedures indicated for trauma patients in 2019.
CT Scans/ MRI on Trauma Patients in the ED
CT SOFT TISSUES OF NECK 1 CT VESSELS OF HEAD AND NECK 3 CT THORACIC CAVITY 3 CT PARANASAL SINUS 6 CT ABDOMINAL CAVITY 8 CT TOTAL BODY (CHEST, ABDOMEN, PELVIS) 19 CT SPINE 21 CT HEAD 31
0 10 20 30 40
Figure 31- CT Scans/MRI on Trauma Patients in the ED
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14.2 Procedures Performed by EMS
The following data represents procedures performed by EMS prior to patient arrival at the NLRHC. This data excludes all walk in patients. Intravenous access and oxygen administration are the greatest number of procedures performed for trauma patients by EMS.
Procedures Performed by EMS (Walk-ins Excluded) NO EMS INTERVENTIONS 15 INTRAOSSEOUS … 1 ASSISTED VENTILATION 1 ORAL/NP INTUBATION 3 C-SPINE … 7 BACKBOARD 9 OXYGEN … 10 PERIPHERAL IV 42
0 10 20 30 40 50
Figure 32- Procedures Performed by EMS (Walk-ins Excluded)
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15.0 Journey of the Trauma Patient
The trauma patient is received at the scene by Emergency Medical Services (EMS); in the RMWB this consists of Alberta Health Services, and private employer EMS. Unless initially treated at a rural/remote medical center; trauma patients are transported to the NLRHC. Trauma patients are then assessed, managed and stabilized in the Emergency department where the decision is made to treat on site; or if a higher level of care is required. If the trauma patient requires care services beyond those available at the Level III center they are transported to closest Level I trauma center. Trauma patients admitted to the NLRHC may be transported to Intensive Care, the Operating Room and or the Surgical Inpatient unit. An inpatient will receive in house rehabilitation services and upon discharge referred to those available as an outpatient.
ICU,Operating Room, EMS Emergency NLRHC Inpatient Surgical Unit OR Transfer Level I
Rehabilitaion Outpatient Rehabilitaion Center/Home/Repatriation Services to NLRHC
Figure 33- Journey of the Trauma Patient
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15.1 Patient Discharge Disposition
Of all major traumas received at the NLRHC Emergency department, 42% were transferred to a higher level of care. Of the remaining; 55% were admitted to an inpatient bed at the NLRCH, with 3% recorded as a death. This shows a decrease in transported patients and an increase in admitted patients from 2016- 2018 data, where 49% were transferred to higher level of care and 49% were admitted to the NLRHC.
ED Patient Disposition - Major Trauma Inpt then Transferred to Level I or II Inpt then Morgue 1 1 4% 3%
From ED to Level I or II 11 38%
Inpt then Home 16 55%
Figure 34- ED Patient Disposition - Major Trauma
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15.2 Destination of Transferred Patients ED and Inpatient
The graph below represents the distribution of receiving trauma centres for patients transferred out of the NLRHC. The University of Alberta Hospital is the primary Level I receiving site for adult trauma and the Stollery for pediatric trauma patients. As evidenced in the data below the majority of major trauma patients are transferred out to the University of Alberta Hospital.
Transfer Destination of Major Trauma Patients
Inpt to UAH 1 8%
ED to UAH ED to RAH 9 2 75% 17% Inpt to RAH 0 0%
Figure 35- Transfer Destination of Major Trauma Patients
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16.0 Admission Service
The Trauma Association of Canada (2011), recommends in the absence of a dedicated Trauma Unit, the surgical unit should be designated to cohort trauma patients together, unless intensive care is required. Ideally, all admitted trauma patients would also be admitted under an intensivist or surgeon. The following data demonstrates the dispersion of trauma patients admitted to the NLRHC. In 2019 admission to ICU almost doubled from 2016-2018 (17%), there was an increase in surgical admissions by 12%, and Medical/Palliative admissions decreased by 4%.
Destination of Trauma Patients Admitted as Inpatients to NLRHC
ICU 30%
Palliative * 2% Surgical 65% Pediatric 3% Figure 36- Destination of Trauma Patients Admitted as Inpatients to NLRHC Palliative* elderly male, fell down stairs, had multiple head injuries, unconscious at presentation.
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16.1 ED Length of Stay by Discharge Disposition
The following data represents the median and average length of stay by discharge disposition years 2019.
ED Discharge To: Number of Patients Median LOS Average LOS Transferred Out 28 3H 57M 4H 50M Surgical Unit 19 7H 15M 7H 33M ICU 11 4H 51M 5H 21M Pediatric Unit 1 4H 55M 4h 55M Operating Room 9 3H 23M 4H 5M Home or Self Care 9 3h 12M 3h 55M Palliative Care 1 6H 2M 6H 2M Direct Admit 4 N/A Figure 37- ED Length of Stay by Discharge Disposition
*Direct Admit – patients admitted for surgical interventions (penetrating injury)
16.2 ED Length of Stay by ISS
The following data represents Emergency department median length of stay by injury severity score (ISS), for 2019.
ISS Number of Patients Median LOS Average LOS All ISS 78* 5H 1M 5H 34M ISS 0-11 50 4H 43M 5H 12M ISS 12-15 10 5H 42M 6H 34M ISS 16/19 3 7H 53M 6H 52M ISS 20-24 2 6H 12M 6H 12M ISS 25-40 12 5H 00M 4H 54M ISS 41-75 1 3H 3M 3H 3M Figure 38- ED Length of Stay by ISS
*Excludes 4 direct admit cases bypassing the ED
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16.3 Trauma Center Inpatient Length of Stay by ISS
The below table demonstrates the inpatient median length of stay (LOS) by ISS 2019.
All ISS Number of Patients: Median LOS: Range: ISS 0 - 11 26 2 01-50 days ISS 12 - 15 6 3 01-18 days ISS 16 - 19 4 10 04-114 days ISS 20 - 24 2 6 04-09 days ISS 25 - 40 4 3 01-09 days ISS 41 - 75 0 n/a n/a Figure 39- Trauma Center Inpatient Length of Stay by ISS
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17.0 Mortality Rates by ISS
From 2011-2019 there were 30 deaths related to major trauma in the region, all with an ISS ≥16 with 7 exceeding an ISS of 40. In 2019 of 28 major trauma patients, one patient was transferred from the ED into hospice care and died there. The following data represents mortality by ISS over years 2011-2019.
Mortality by ISS 2011-2019
18 1 16 2 14 1 12 5 10 8 3 6 2 1 4 2 5 5 2 1 1 1 1 1 0 ISS 0-11 ISS 12-15 ISS16-19 ISS 20-24 ISS 25-40 ISS≥41 2019 1 2018 2 2017 1 2016 1 2015 1 2 2014 1 1 5 2 2013 3 2012 1 2011 1 5 5
2011 2012 2013 2014 2015 2016 2017 2018 2019
Figure 40 - Mortality by ISS 2011-2019
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18.0 Post Transfer Complications
According to the Canadian Institute for Health Information’s, National Trauma Registry Comprehensive Dataset – Data Dictionary (2012), A complication or complications can arise “after the beginning of hospital observation and/or treatment that usually has a significant influence on the patient’s hospitalization (length of stay) and/ or the patient’s management or treatment”. Below is the data for reported complications of major traumas transferred from NLRHC to Level I and II facilities. Two patients experienced complications after transfer for 2019; one with a stroke/CVA the second with ventilator associated pneumonia. (Data provided by University of Alberta Hospital and Royal Alexandra Hospital trauma analysts)
Complications of Patients Transferred to Level I and II Facilities, ISS ≥ 12
8
2 2 0 UAH RAH
Complications No Complications
Figure 41 - Complications of Patients Transferred to Level I and II Facilities, ISS ≥ 12
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All complications recorded by the NLRHC 2019, for major traumas ISS ≥ 12 are represented in the following graph. Pneumonia and cardiac arrest with CPR are the most frequent complications noted with major trauma patients.
Complications During Hospital Admission
UNPLANNED RETURN TO OR 1
OTHER* 2
UNPLANNED ADMISSION TO ICU 1
CARDIAC ARREST WITH CPR 2
ALCOHOL WITHDRAWAL SYNDROME 1
PNEUMONIA 2
0 0.5 1 1.5 2 2.5
Figure 42 - Complications of Major Traumas Recorded by NLRHC, During Hospital Admission *Other include: 1. Hypoxemic respiratory failure (combination of abdominal distension, narcotics and atelectasis. 2. Clysis tip (foreign body) in the arm.
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19.0 Performance Improvement and Patient Safety (PIPS)
NLRHC actively participates in Performance Improvement and Patient Safety (PIPS) program. An extensive chart review for all trauma patients with an ISS ≥ 12, or any called or missed Trauma Team Activations. By utilizing built in audit filters within the collector, as well as external performance indicators, charts are retrospectively reviewed by the trauma coordinator to identify any issues that may affect the quality of patient care. When issues are identified, the review is taken to the PIPS committee, comprised of the Trauma Medical Director, Trauma Coordinator and Manager of the Emergency Department for further review. Issues are resolved by: . Speaking with healthcare provider directly . EMS issues are taken to EMS directors by the Trauma Medical Director . Education and policy development for identified issues becoming trends in patient care . Collaboration with The Emergency/ICU Quality Nurse
Current improvement strategies involve nursing considerations and trauma charting, use of C-Collar and spinal precautions, and appropriate use of adult and pediatric TTA criteria.
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20.0 Audit Filters The Trauma Association of Canada (TAC) requires a comprehensive trauma registry, as part of the guidelines for an accredited trauma system/trauma center. Alberta utilizes the Alberta Trauma Registry (ATR) for data collection. Audit filters are the provincial filters utilized by the ATR guiding data collection.
Audit Filters NA NO UNKNOWN YES TOTAL
<200km arrival within 2.5 hours 28 2 4 48 82
>400Km arrival within 6 hours 80 1 1 82
200-400km arrival within 6 hours 78 1 3 82
Consult Gynecology arrived within 30 minutes of TTA call 81 1 82
Consult Orthopedic Surgeon Arrived within 30 minutes of TTA 66 4 6 6 82 call
Consult Pediatrics arrived within 30 minutes of TTA call 79 3 82
Consult Surgery arrived within 20 minutes of TTA call 66 1 10 5 82
Coordinator Consult received 47 35 82
EMS patch form completed 21 13 1 47 82
Massive Transfusion Protocol ordered 44 36 2 82
Trauma Record Utilized 1 50 31 82
Trauma Set Form completed 81 1 82
TXA First Dose given 52 21 9 82
TXA Second dose given 52 26 4 82
TXA given by EMS 52 29 1 82
TXA in ED 52 25 5 82
Figure 43- NLRHC Audit Filters 2019
Review of the audit filter results from previous years helps guide the education and goals of the Trauma Program. Documentation, TTA response, and EMS PCR compliance have been and continue to be a priority for 2019.
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Works Cited
Accreditation Canada. (2018). Trauma Distinction. Retrieved on October 15, 2018. https://accreditation.ca/trauma-distinction/ Alberta Health Services. (2019). Injury Prevention & Safety – For Health Professionals. Retrieved March 6, 2019. https://www.albertahealthservices.ca/injprev/Page4791.aspx Association for the Advancement of Automotive Medicine. (2005). Abbreviated Injury Scale (AIS) 2005 Manual, 5. Bascaramurty, Dakshana. (2017).The long, dangerous road to Fort McMurray. Globe and Mail. Retrieved November 16, 2018. https://www.theglobeandmail.com/news/alberta/suicide-63-the-deadly-route-into-fort- mcmurray-finally-set-to-befixed/article28627352/ Bakx, Kyle. (2018).The great oil sands era is over. Retrieved December 12, 2018. https://newsinteractives.cbc.ca/longform/the-great-oilsands-era-is-over Canadian Institute for Health Information. (2012). National Trauma Registry Comprehensive Data Set-Data Dictionary. Retrieved April 6, 2019. https://www.cihi.ca/en/ntr_cds_data_2012_en.pdf Injury Prevention Center. Alcohol & Injuries. Knowledge, Leadership, Action. Retrieved March 12, 2019.https://injurypreventioncentre.ca/issues/alcohol Injury Prevention Center. Quad & OHV Injuries. Knowledge, Leadership, Action. Retrieved March 12, 2019. https://www.injurypreventioncentre.ca/issues/ohv Injury Prevention Center. (2019). Motor Vehicle Injuries. Knowledge, Leadership, Action. Retrieved March 13, 2019. https://injurypreventioncentre.ca/issues/vehicles Kornik, Slav and Mertz, Emily. (2016). “It’s eerie”: Thousands of residents return home after Fort McMurray wildfire. Global News. Retrieved November 12, 2018. https://globalnews.ca/news/2734097/fort-mcmurray-wildfire-phased-re-entry-to-begin- wednesday-officials-asking-residents-to-respect-plan/ Marksoff, Jason. (2017). Why Fort McMurray will never be the same. McLeans. Retrieved December 6, 2018. https://www.macleans.ca/news/canada/why-fort- mcmurray-will-never-be-the-same/ McDermott, Vincent. (2019). Three years after the wildfires, Fort McMurray rebuild marked by court fights, sluggish rebuild. Retrieved July 17, 2019. https://edmontonjournal.com/news/local-news/three-years-after-the-wildfire-fort- mcmurray-rebuild-marked-by-court-fights-sluggish-rebuild
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Ministry of Transportation, Government of Alberta. Highway 63. 2017. Retrieved November 22, 2018. https://www.transportation.alberta.ca/4942.htm Ministry of Transportation, Government of Alberta. (2015). Highway 63 twinning now 99 percent complete. Retrieved November 22, 2018. https://www.alberta.ca/release.cfm?xID=386990B1BA319-BD5C-BC56- 5428BEB65AF933A2
Northern Alberta Development Council; Alberta Aboriginal and Northern Affairs. (2016). Shadow Populations in Northern Alberta. Retrieved December 6, 2018. https://www.nadc.gov.ab.ca/Docs/Shadow-Populations.pdf
Parachute Canada. (n.d) All-terrain vehicle safety. Retrieved October 22, 2018. http://www.parachutecanada.org/injury-topics/topic/C1
Regional Municipality of Wood Buffalo. Municipal Census Report; Census 2018. Retrieved February 10, 2020. http://www.rmwb.ca/Assets/Departments/Planning+and+Development/Planning+$!26+D evelopment+Documents/Census+Report+2018.pdf Statistics Canada, (2017). Fort McMurray Census Profile. 2016 Census. Statistics Canada Catalogue. Ottawa. Retrieved November 16, 2018. https://www12.statcan.gc.ca/census-recensement/2016/dp- pd/prof/details/page.cfm?Lang=E&Geo1=POPC&Code1=0292&Geo2=PR&Code2=48& Data=Count&SearchType=Begins&SearchPR=01&B1=All&TABID=1 Statistics Canada. (2010). Injured in Canada: Insights from the Canadian Community Health Survey. Retrieved November 16, 2018. https://www150.statcan.gc.ca/n1/pub/82- 624-x/2011001/article/11506-eng.htm Trauma Association of Canada. (2011). Trauma System Accreditation Guidelines. Fourth Revision. https://www.traumacanada.org/wp- content/uploads/2019/05/Accreditation_Guidelines_2011.pdf Thurton, David. (2018). Economic Bust: Fort McMurray’s new normal. Retrieved July 17, 2019. https://www.cbc.ca/news/canada/edmonton/half-decade-economic-bust-fort-mcmurray- new-normal-1.4947579
World Health Organization. (2018). Injuries. Cited November 21, 2018. http://www.who.int/topics/injuries/about/en/
World Health Organization, (2004). Guidelines for essential trauma care. Geneva. Retrieved November 22,2018. http://canadiantraumanurses.ca/pdf/guidelines_traumacare.pdf
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Figures
Figure 1- Major Trauma Cases vs. Minor Trauma 2016-2019 ...... 12 Figure 2-Major Trauma by Year, 2011-2019 ...... 14 Figure 3- Major Trauma (ISS≥12) by Injury Type ...... 15 Figure 4- Type of Injury by ISS Range ...... 16 Figure 5- Major Trauma by ISS ...... 17 Figure 6-Average ISS of Trauma Patients 2012-2019 ...... 18 Figure 7- Comparison of Average ISS of Major Trauma and Number of Major Trauma Patients 2012-2019 ...... 19 Figure 8 - Trauma by Location of Primary Residence ...... 20 Figure 9- Trauma Team Activation - 2018 ...... 21 Figure 10- Trauma Team Activations 2019 ...... 21 Figure 11- Trauma Team Activations and Time to CT 2016-2018* ...... 22 Figure 12- Trauma by Admission Month ...... 25 Figure 13- Major Trauma by Admission Day of the Week ...... 26 Figure 14-Time of Day Qualifying Patients Presented to ED ...... 27 Figure 15 - Major Trauma by Time of Day 2016-2018 ...... 27 Figure 16 - Mode of Arrival All Qualifying Patients ...... 28 Figure 17-Post ED Disposition, Regardless of ISS ...... 29 Figure 18- Type of Injury, All Qualifying Trauma Patients ...... 31 Figure 19- Mechanism of Injury 2016, 2017, and 2018 vs 2019 ...... 32 Figure 20- Major Trauma by Mechanism and Age Ranges ...... 33 Figure 21- Mechanism of Injury with Major Trauma ...... 34 Figure 22- Mechanism of Injury with ISS≥12 vs. Criteria Met and TTA Called ...... 35 Figure 23- Major Trauma by Place and Mechanism of Injury ...... 36 Figure 24- Work-related Trauma by Age, Regardless of ISS ...... 37 Figure 25- Work-related Trauma by Mechanism of Injury ...... 38 Figure 26- Mode of Transportation Resulting in Injury 2016-18 vs 2019 ...... 40 Figure 27- Major Trauma in Transportation, Restraint/Protective Device ...... 41 Figure 28- ETOH Levels, All Trauma Patients ...... 42 Figure 29- Major Trauma (ISS>12) with ETOH Levels ...... 43 Figure 30- Procedures on Trauma Patients in the ED ...... 44 Figure 31- CT Scans/MRI on Trauma Patients in the ED ...... 45 Figure 32- Procedures Performed by EMS (Walk-ins Excluded) ...... 46 Figure 33- Journey of the Trauma Patient ...... 47 Figure 34- ED Patient Disposition - Major Trauma ...... 48 Figure 35- Transfer Destination of Major Trauma Patients ...... 49
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