ALBERTA CHILDREN’S HOSPITAL PEDIATRIC · PDF fileALBERTA CHILDREN’S HOSPITAL . PEDIATRIC ... introduction of Advanced Trauma Life Support ... Program held its first annual offering

1

ALBERTA CHILDREN’S HOSPITAL

PEDIATRIC TRAUMA PROGRAM

ANNUAL REPORT

2012 – 2013

ACH Trauma Program Staff

Dr. Angelo Mikrogianakis (until July 2012) ..................... Co - Medical Director

Dr. Mary Brindle (until July 2012) .................................... Co - Medical Director

Dr. Jonathan Guilfoyle (started July 2012) ............................. Medical Director

Rod Iwanow (until Sept 2012) ................................ Trauma Program Manager

Sharleen Luzny (started Sept 2012) ...................... Trauma Program Manager

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

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

2

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

3

1. Introduction The year 2012-2013 was a year of change and growth for the Pediatric Trauma Program at Alberta Children’s Hospital. Dr. A. Mikrogianakis and Dr. M. Brindle, who had shared the role of interim Medical Director, stepped down and Dr. J. Guilfoyle began his term as Medical Director. In addition, Mr. Rod Iwanow, the former Trauma Program Manager, moved on and has now been replaced by Ms. Sharleen Luzny. We would like to recognize the hard work and dedication of those leaving their positions and welcome the enthusiasm and energy of our new members. We are also very appreciative of everyone’s cooperation to make this a smooth and seamless transition. The Trauma Program continues to strive to implement all of the recommendations made in the 2010 Trauma Association of Canada (TAC) Accreditation. Due to the hard work of the radiology department we are now pleased to be able to provide a 24/7 Interventional Radiology service. This is an important step towards our goal of repatriating the 15 – 17 year old population currently being cared for at the Foothills Medical Centre. A prime focus for the Trauma Program in the last year and moving forward is the institution of an on-call Trauma Team Leader (TTL) Program. Currently the Emergency Physician on shift is the default TTL and the lack of a designated on-call TTL Program was identified as a deficiency in our most recent TAC Accreditation. This past year another formal funding proposal was put forward to fund this initiative, but due to fiscal restraints was not approved. We will continue to work to drive this initiative forward. 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). Of note, our Pediatric Trauma Coordinator, Ms. Sherry MacGillivray, is the current co-chair for the Pediatric Committee of TAC. In 2012-2013, the ACH Trauma Program continued to provide educational leadership for both ACH clinical staff as well as outreach education to rural and regional providers. On-going education provided by the Pediatric Trauma Program includes: mock/just-in-time trauma codes for the ED; monthly Pediatric Trauma Rounds; twice yearly Trauma Nursing Core Courses (TNCC); the introduction of Advanced Trauma Life Support (ATLS) held at ACH and outreach education to referral centres by partnering with KidSIM™, the Pediatric Human Patient Simulation Program at ACH. We would like to take a moment to highlight two of these educational endeavors that were newly introduced in the past year. In the fall of 2012 the ACH Trauma Program held its first annual offering of the Advanced Trauma Life Support (ATLS) course. The course was run by senior ACH faculty and catered

4

specifically to the learning needs of the multidisciplinary trauma team at ACH. The course was extremely well received and will now be run annually in the fall. Through the collaboration of the Trauma Program and the ECMO program at ACH we will be able to offer Advanced Trauma Procedural Skills Labs. This attending-focused lab will allow participants to practice advanced procedures including chest tube insertion, emergent thoracotomy and surgical airways. A date is booked in the spring of 2013 with plans to make it a semiannual event. We would like to thank all of our trauma educators for outstanding teaching throughout the year. The ACH Trauma Program would also like to thank the Alberta Children’s Hospital Foundation, who has continued to support our education initiatives in terms of TNCC and simulation. We also wish to thank all of the staff at the Alberta Children’s Hospital who have had an impact on the Pediatric Trauma Program, and who continue to support our goals in caring for critically injured children and youth. In particular, a great deal of thanks goes to the nurses, physicians, respiratory therapists, and other front-line staff who remain devoted to the care of these children and their families, as well as all of the other staff who make excellence in Pediatric Trauma Care at the Alberta Children’s Hospital a veritable “team effort”. On a personal note, Dr. J. Guilfoyle would like to extend a heartfelt thank you to all the members of the Trauma Program for such a warm welcome and ongoing support. He would like to thank Dr. A. Mikrogianakis and Dr. M. Brindle for their mentorship and continued support. Above all, he would like to thank Ms. Sherry MacGillivray for her tireless efforts and dedication to our 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.

5

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. There were no significant changes in 2012-2013.

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 led by the Division of Pediatric General Surgery. They provide attending physician coverage for this service 24/7. There were no significant changes in 2012-2013.

iii) Trauma Tertiary Survey

• The Pediatric Trauma Tertiary Survey was revised in 2011 and continues to be completed by the in-patient trauma service on all major trauma patients at 24 hours after admission.

iv) Pediatric Trauma Nurse Practitioner

• This position was developed to support the in-patient trauma service, as well as the medical needs of rehabilitation patients in the hospital and to play a significant role on the Brain Injury Team. In 2012-2013 this position was re-evaluated, resulting in a dedication to trauma patients only as well as coverage for time away. This past year the Trauma Nurse Practitioner also started outpatient follow up Trauma Clinics.

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 ‘under’ triage and for any issues that arise. Our goal is to undertriage < 5%. The literature suggests this might mean an overtriage rate up to 50%. The undertriage rate for 2012-2013 was 2% with an overtriage rate of 40%, meaning we are appropriately meeting those targets.

6

vi) OR Activation (Code 88) • A Code 88 activation is called in order to mobilize the OR team

for an anticipated emergent airway intervention and/or an anticipated need for an emergent OR. This is an automatic 24/7 response from Anesthesiology, Anesthesia RRT, OR Nursing team (3 RN’s), PACU nursing team (2 RN’s). The Pediatric Intensivist is also on the activation for those times they are in-house and can assist with a difficult airway. Activations are monitored and reviewed by the Trauma Committee.

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 2012-2013 completion rate was 88%, which is a significant increase from last year.

viii) Provincial Nursing Trauma Resuscitation Record

• As a directive from the Provincial Trauma Committee, the Alberta Trauma Coordinators (ATC) developed a provincial nursing trauma record to be used in all emergency departments and urgent care centers in the province. This record took 18 months to develop but was felt to be an important standardization of trauma care and management. It was initiated in July 2012 and will be reviewed by the ATC for necessary revisions in one year.

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 that are 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.

7

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 an on-going program. The opportunity for admitted trauma patients to mark and remember their journey by earning beads for length of hospital stay, diagnostic tests and treatment modalities has been well received by both trauma patients and their families. This program, administered by the Pediatric Trauma Coordinator and operationalized by the ACH Child Life Specialists, has been a huge success. We would like to extend our gratitude to the ACH Foundation and the ACH Child Life Specialists for making this important program a continued success.

xii) ACH Trauma Manual

• After a thorough revision and overhaul, the ACH Trauma Manual was approved and published by the Trauma Committee February 7, 2013. Thank you to all those who contributed and also to Lisette Lockyer, Trauma Nurse Practitioner, showing dedication and perseverance for its completion.

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

8

3. Education

i) Trauma Rounds Rounds were moved to the ACH Ampitheatre in December 2012 to accommodate telehealth to outside centres

• May 10, 2012 - Dr. Russell Lam “A Pre-Arrival Checklist for

Pediatric Polytrauma”

• June 4, 2012 - Dr. Angelo Mikrogianakis “National Pediatric Trauma Course”

• September 13, 2012 - Dr. Mary Brindle “Pediatric Pancreatic

Trauma”

• October 4, 2012 - Dr. Ulrich Amendy “Interventional Radiology in Pediatric Trauma”

• November 8, 2012 - Dr. Naminder Sandhu “Spinal Cord Injuries in Pediatrics”

• December 13, 2012 - Dr. Richy Lee “Abdominal Compartment Syndrome”

• January 24, 2013 - Dr. Jonathan Gamble “Propofol and Pediatric Trauma”

• February 28, 2013 - Calgary Zone EMS Educators “Walk a Mile in our Shoes”

• March 28, 2013 - Dr. Karen Barlow and Lisette Lockyer “Traumatic Brain Injury or Concussion?”

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. This course is partially funded by a generous grant from the Alberta Children’s Hospital Foundation.

iii) Mock/Just-in-Time Trauma Codes

• These simulated mocks provided ED physicians, fellows, residents, nurses, respiratory therapists, nursing aides and unit clerks with an opportunity to learn from simulated trauma cases.

9

iv) Advanced Trauma Life Support • Advanced Trauma Life Support (ATLS) is a course for doctors

that teaches a systematic, concise approach to early care of the trauma patient. We were pleased to host this course for the first time at ACH in Oct 2012 with plans to make it a yearly event.

v) 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 2012-2013:

April 2012 Olds, Three Hills May 2012 Medicine Hat, Cardston, Fort McLeod, Black Diamond June 2012 Vulcan, Cranbrook BC Oct 2012 Claresholm, Lethbridge Nov 2012 Red Deer, Pincher Creek, Crowsnest Pass, South

Health Campus Calgary Dec 2012 Golden BC, South Health Campus Calgary Jan 2013 Canmore Feb 2013 Sheldon Chumir, South Health Campus Calgary March 2013 Black Diamond, Sundre

vi) Emergency Trauma Simulation Sessions • Trauma simulation sessions were held for ED nurses as part of

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

vii) Nursing Trauma Simulation Sessions

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

10

viii) University of Calgary, Undergraduate Medical Education • Course VI Lecture on the Approach to Pediatric Trauma – Dr. J.

Guilfoyle • Pediatric Trauma simulation with medical students continues as

part of their curriculum and is always well received.

ix) Pediatric Advanced Trauma Course (PATC) (Calgary, AB – March 2012) • This course was a national initiative built by a multidisciplinary

team of trauma and simulation experts from across Canada in 2011. Going forward it will be offered by the College of Physicians and Surgeons of Canada and will be known as Trauma Resuscitation in Kids (TRIK) – Dr. Angelo Mikrogianakis, Sherry MacGillivray

x) Central Zone Trauma Education Day (Red Deer, AB – Sept 2012)

• Pediatric Case Study and Pitfalls - Sherry MacGillivray

xi) Trauma Association of Canada Annual Scientific Meeting (Toronto, ON – April 11-13, 2012) • Interdisciplinary Trauma Network of Canada Rapid Fire

Presentation “ Southern Alberta Trauma System Accreditation” - Sherry MacGillivray

11

4. Research

The following research projects were in progress or completed during 2012-2013:

PUBLICATIONS:

1) Decloe M, Emery CA, Hagel BE, Meeuwisse WH. Injury rates, types, mechanisms and risk factors of injury in female youth ice hockey. British Journal of Sports Medicine. bjsports-2012-091653 Published Online First: 27 February 2013 doi:10.1136/bjsports-2012-091653

2) Karkhaneh M, Rowe BH, Saunders D, Voaklander D, Hagel BE. Trends in head injuries associated with mandatory bicycle helmet legislation targeting children and adolescents. Accident Analysis & Prevention, 59: 206-212

3) Romanow NTR, Couperthwaite A, McCormack GR, Nettel-Aguirre A,

Rowe BH, Hagel BE. Assessing inter-rater agreement of environmental audit data in a matched case-control study on bicycling injuries. Injury Prevention. Inj Prev doi:10.1136/injuryprev-2012-040500

4) Romanow NTR, 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) Romanow, NTR, Couperthwaite A, McCormack GR, Nettel-Aguirre A,

Rowe BH, Hagel, BE. Environmental determinants of bicycling injuries. Journal of Environmental and Public Health, Volume 2012, Article ID 487681, 12 pages; doi:10.1155/2012/487681

6) Morrongiello BA, Sandomierski M, Hagel BE, Schwebel DC. Are parents

just treading water? The impact of participation in swim lessons on parents’ judgments of children’s drowning risk, swimming ability, and supervision needs. Accident Analysis & Prevention 2013 Jan; 50:1169-75. doi: 10.1016/j.aap.2012.09.008. Epub 2012 Oct 6

7) Blake T, Hagel BE, Emery CA. Sport Medicine Journal Club: “Does

Intentional or Unintentional Contact in Youth Ice Hockey Result in More Injuries?” [Commentary] Clinical Journal of Sport Medicine 2012;22(4): 377–378

8) Branson LJ, Latter J, Currie G, Nettel-Aguirre A, Embree T, Hagel BE.

The effect of surfacing and season on playground injury rates. Paediatrics & Child Health 2012;17(9) 485-489

12

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

10) Blanchard I, Doig CJ, Hagel BE, Anton AR, Zygun DA, Kortbeek JB,

Powell DG, Williamson TS, Fick GH, Innes GD. Emergency Medical Services Response Time and Mortality in an Urban Setting. Prehospital Emergency Care 2012; 1(Jan/March):1-10. Posted online on 25 Oct 2011: doi: 10.3109/10903127.2011.614046

11) Karkhaneh M, Hagel BE, Couperthwaite A, Saunders D, Voaklander DC,

Rowe BH. Emergency department coding of bicycle and pedestrian injuries during the transition from ICD-9 to ICD-10. Injury Prevention 2012 Apr;18(2):88-93

IN PROGRESS:

1) Romanow NTR, Hagel BE, Williamson J, Rowe BH. Bicyclist head and facial injury risk in relation to helmet fit: a case-control study. Accepted: Chronic Diseases and Injuries in Canada

2) 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. Accepted: British Journal of Sports Medicine

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

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

4) Brindle ME, Beres AL, Wales PW, Christison-Lagay ER, McClure E, Fallat

E. Nonoperative management of high grade pancreatic trauma: Is it worth the wait?

5) Russell K, Meeuwisse WH, Nettel-Aguirre A, Emery CA, Wishart J, Ruest

N, Rowe BH, Goulet C, Hagel BE. Characteristics associated with snowboarders who bypass the ski patrol and present only to the Emergency Department. Accepted: International Journal of Injury Control and Safety Promotion

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

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

13

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 2012-2013 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?

14

6. Future Planning The 2013-2014 year will focus on the following activities: • Obtaining dedicated funding for a formal Trauma Team Leader program • Continuing to collect data in terms of the care and needs of 15-17 year old

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

• Continuing to focus on quality Pediatric Trauma Education • Continuing advocacy of injury prevention initiatives • Continuing leadership on a regional, provincial and national level • Continuing an active pediatric trauma research program • Continuing excellence in quality assurance leadership • Focusing on improving communication with all of the services impacted in

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

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

ACH Trauma Quality Indicators (ISS >12) 2012/2013

15

Appendix A Alberta Children’s Hospital Trauma Quality Indicators for 2012/2013 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

2012/2013, n = 62 62 0 2011/2012, n = 77 71 6 2010/2011, n = 66 61 5 2009/2010, n = 69 65 4 2008/2009, n = 64 54 10

Cooperation with Alberta Health Services EMS since Nov 2011 now allows on-line record access which has improved the compliance of this indicator tremendously. 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

2012/2013, n = 10 5 5 2011/2012, n = 11 2 9 2010/2011, n = 6 3 3 2009/2010, n = 5 2 3 2008/2009, n = 11 3 8

Pediatric experts advise that it is best practice to move the injured pediatric patient from the scene quickly to acute care for intubation, if required, rather than attempt intubation at the scene. These patients are reviewed at the Pediatric Trauma Quality Management Committee to ensure appropriate care was given.


16

3. Length of stay at rural hospital greater than two hours.

Was the length of stay at a rural hospital > 2 hours? Exclusions: Inappropriate - patients had no first or second hospital. Unknown - missing arrival or departure time at first or second hospital Inclusions: n = all patients arriving at ACH from hospitals outside Calgary.

Indicator Yes No

2012/2013, n = 28 19 9

2011/2012, n = 33 20 13

2010/2011, n = 35 24 11

2009/2010, n = 25 16 9

2008/2009, n = 29 21 8

If at any time the ACH Pediatric Trauma Quality Management Committee feels that the Rural Hospital LOS is not acceptable, a letter to that hospital is sent for clarification of the timeline and appropriately followed up. The significant percentage of cases with a prolonged rural stay remains a concern and education around the importance of timely disposition and transfer of major trauma patients remains a priority. This is also a Provincial Trauma Committee indicator that is being monitored across the Province. 4. Injury time to trauma centre < 4 hours for transferred patients.

Did the patient arrive at a trauma centre < 4 hours from the time of injury? Trauma Centre is defined as ACH, FMC, U of A or Stollery Hospitals in Edmonton. As well as Red Deer, Lethbridge or Medicine Hat Hospitals. Exclusions: Out of the patient transfers, 3 patients were transferred from within Calgary, 7 from Lethbridge, 3 from Red Deer and 2 from Medicine Hat resulting in a total (n) 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 2012/2013, n = 13 7 6 2011/2012, n = 22 9 13 2010/2011, n = 22 5 17 2009/2010, n = 18 4 14 2008/2009, n = 13 1 12

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. This has been a priority for the Provincial Trauma Committee and revisions of pre-hospital transport algorithms and guidelines can be seen in the improvement this past year. Also note that there were three patients that had unknown time of injury this past year.


17

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 2012/2013, n = 31 7 24

2011/2012, n = 42 9 33

2010/2011, n = 40 13 27

2009/2010, n = 31 5 26

2008/2009, n = 33 6 27

The Alberta Children’s Hospital offers a specialized Pediatric Transport Team Service, which transports critically ill or injured children from referring centers located in southern Alberta, south-eastern British Columbia, and south-western Saskatchewan. The transport team travels by ambulance, helicopter or fixed-wing aircraft and provides quality pediatric critical care to the residents of these areas who do not otherwise have access to pediatric critical care specialists. Through Link Center communications, medical control and mobilization of the team is achieved via the PICU attending physician. The team consists of a respiratory therapist (RT) and an ACH ED or PICU registered nurse (RN) with a physician on call for difficult cases. This Service has gone through recent changes which have increased the efficiency of mobilization, thereby making it a more feasible alternative for the transport of acutely injured children.


18

Resuscitative care: 6. Trauma Team Activation

Trauma Team Activation (Code 77) is the responsibility of the ED nurse answering the EMS patch phone using specific criteria that were developed by the Pediatric Trauma Committee. These include physiologic, anatomic and co-morbid factors, as well as mechanism of injury. The above graph illustrates Code 77 activation for the major trauma population only (ISS > 12). In some cases, the trauma team may be called however the patient does not meet the Trauma Registry inclusion criteria. 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 2012/2013, n = 76 4 72 2011/2012, n = 89 7 82 2010/2011, n = 82 11 71 2009/2010, n = 82 8 74 2008/2009, n = 74 15 59

There is currently a No Direct Admit Policy for trauma patients – meaning they should stop in the ED for assessment. However if the injury is more than 24 hours old this policy does not apply. This past year, 2 of the 4 patients were directly admitted with injuries older than 24 hours. From the remaining 2 patients; one was sent appropriately to the PICU from the FMC once the age was determined and the remaining one was discussed at the Pediatric Trauma Quality Management Committee.

1

4

2

5 5

21

3

0

3

1

332

4

2

45

3

1 1 1

32

8

5

7

910

8

10

67

4

9

7

4 4 4

65

2

0

21

23

2

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

# of

Act

ivat

ions

Major Trauma Team Activation 2009/2010 to 2012/2013

2009/2010 2010/2011 2011/2012 2012/2013


19

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

2012/2013, n = 2 2 0

2011/2012, n = 0 0 0

2010/2011, n = 2 2 0

2009/2010, n = 4 3 1

2008/2009, n = 5 5 0

This past year, 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

2012/2013, n = 72 34 38

2011/2012, n = 83 30 53

2010/2011, n = 71 25 46

2009/2010, n = 75 31 44

2008/2009, n = 59 28 31

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 standard ED documentation of hourly.


20

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

2012/2013, n = 59 44 15

2011/2012, n = 65 47 18

2010/2011, n = 64 44 20

2009/2010, n = 62 38 24

2008/2009, n = 52 36 16

Trauma Packs, which include a separate Neurological Vital Sign sheet, are used in the ACH ED Trauma Room to remind nurses to trend this important vital sign. 11. Hypothermic in the ED (<35.0 degrees C)

Was the patient hypothermic in the emergency department? Temperature was recorded at <35.0 degrees C. Exclusions: Direct admits and unknown/missing ED temp. Inclusions: n = all patients seen in ED.

Indicator Yes No

2012/2013, n = 67 2 65

2011/2012, n = 79 1 78

2010/2011, n = 72 2 70

2009/2010, n = 72 1 71

2008/2009, n = 57 2 55

These two hypothermic patients were reviewed by the Trauma Quality Management Committee where recommendations were made but care was deemed appropriate. It is important to note that there were also 5 patients where a temperature was not recorded in the ED. Ongoing education continues for this important vital sign to be documented.


21

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

2012/2013, n = 14 14 0

2011/2012, n = 14 13 1

2010/2011, n = 11 11 0

2009/2010, n = 12 12 0

2008/2009, 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

2012/2013, n = 72 40 32

2011/2012, n = 81 40 41

2010/2011, n = 72 35 37

2009/2010, n = 75 39 36

2008/2009, n = 59 27 32

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.


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

2012/2013, n = 74 66 8

2011/2012, n = 89 82 7

2010/2011, n = 82 76 6

2009/2010, n = 83 77 6

2008/2009, n = 74 67 7

All 8 patients that were initially admitted to a non-surgeon or an intensivist were deemed appropriate according to ACH Admission Guidelines. All were admitted to the Pediatrics Service: 3 for isolated head injuries less than one year of age, 4 for work up of non-accidental or intentional injuries and 1 with a complicated history. 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

2012/2013, n = 3 2 1

2011/2012, n = 3 3 0

2010/2011, n = 4 4 0

2009/2010, n = 6 6 0

2008/2009, n = 3 3 0

This past year, 1 patient had an acute epidural that was taken to the OR just outside of the 4 hours. A review by the Trauma Quality Management Committee was done and this was not deemed to be inappropriate as the patient was neurologically stable.


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

2012/2013, n = 74 0 74

2011/2012, n = 89 0 89

2010/2011, n = 82 0 82

2009/2010, n = 83 0 83

2008/2009, n = 74 0 74

17. Any laparotomy procedure performed.

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

Indicator Yes No

2012/2013, n = 76 2 74

2011/2012, n = 90 4 86

2010/2011, n = 83 4 79

2009/2010, n = 83 4 79

2008/2009, n = 74 3 71

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.


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

2012/2013, n = 4 4 0

2011/2012, n = 7 6 1

2010/2011, n = 4 3 1

2009/2010, n = 6 6 0

2008/2009, n = 3 3 0

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

2012/2013, n = 1 1 0

2011/2012, n = 2 1 1

2010/2011, n = 1 1 0

2009/2010, n = 0 0 0

2008/2009, n = 0 0 0


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

2012/2013, n = 20 1 19

2011/2012, n = 30 0 30

2010/2011, n = 34 0 34

2009/2010, n = 43 2 41

2008/2009, n = 26 0 26

In 2012/2013 one patient had to return to the OR within 48 hours to remove a foreign body. While foreign bodies themselves are not classified as a trauma, if they cause an internal injury then it is coded as a trauma. 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

2012/2013, n = 74 1 73

2011/2012, n = 89 0 89

2010/2011, n = 82 0 82

2009/2010, n = 82 1 81

2008/2009, n = 74 0 74

A trauma tertiary survey performed by the Trauma Surgery NP, Fellow or Resident at 24 hours after admission to the trauma centre helps to keep missed injuries to a minimum. Unfortunately, this past year there was one patient that was found to have a tibia fracture 16 days after admission. The case was reviewed at the Trauma Quality Management Committee and recommendations were made.


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

2012/2013, n = 1 0 1

2011/2012, n = 3 2 1

2010/2011, n = 0 0 0

2009/2010, n = 2 2 0

2008/2009, n = 0 0 0

This past year one patient did not have her joint dislocation reduced until deemed appropriate by the Orthopedic Surgeon. Care was considered appropriate as per the Trauma Quality Management Committee review. 23. Revascularization of an ischemic limb within 6 hours from the time of injury.

If the patient had an ischemic limb, was it re-vascularized within 6 hours from the time of injury? Exclusions: No ischemic limb or patient died prior to repair. Inclusions: n = all patients with ischemic limb.

Indicator Yes No

2012/2013, n = 0 0 0

2011/2012, n = 0 0 0

2010/2011, n = 0 0 0

2009/2010, n = 0 0 0

2008/2009, n = 0 0 0


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

2012/2013, n = 3 3 0

2011/2012, n = 1 0 1

2010/2011, n = 1 1 0

2009/2010, n = 2 2 0

2008/2009, n = 2 2 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

2012/2013, n = 0 0 0

2011/2012, n = 0 0 0

2010/2011, n = 1 1 0 2009/2010, n = 0 0 0

2008/2009, n = 0 0 0


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

2012/2013 n = 0 0 0

2011/2012 n = 0 0 0

2010/2011, n = 0 0 0

2009/2010, n = 2 0 2

2008/2009, 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

2012/2013 n = 0 0 0

2011/2012 n = 1 0 1

2010/2011, n = 0 0 0

2009/2010, n = 1 1 0

2008/2009, n = 0 0 0


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

2012/2013, n = 74 2 72

2011/2012, n = 89 1 88

2010/2011, n = 82 2 80

2009/2010, n = 82 0 82

2008/2009, n = 74 0 74

This year two patients needed to be transferred to the PICU from the trauma unit due to instability. The PICU Specialized Transitional Educational Personnel (STEP) team was developed in 2011 which aids in these types of quick assessments and transfers.

Did the patient have an unplanned readmission to ICU at the ACH trauma centre? Exclusions: Patients without admission to ICU. Inclusions: n = all patients with at least one ICU admission.

Indicator Yes No

2012/2013, n = 24 0 24

2011/2012, n = 36 3 33

2010/2011, n = 36 1 35

2009/2010, n = 36 0 36

2008/2009, n = 31 1 30

The STEP team follows patients that are transferred out of the PICU to ensure safety, but this past year no patients were re-admitted to the PICU.


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

2012/2013, n = 5 2 3

2011/2012, n = 4 3 1

2010/2011, n = 5 3 2

2009/2010, n = 8 4 4

2008/2009, n = 2 1 1

Unfortunately 2 patients died in the ACH ED in 2012/2013. All death cases were reviewed by the Pediatric Trauma Quality Management Committee and care was deemed appropriate. 30. Did the patient die in ACH?

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

Indicator Yes No

2012/2013, n = 76 5 71

2011/2012, n = 90 4 86

2010/2011, n = 83 5 78

2009/2010, n = 83 8 75

2008/2009, n = 74 2 72

An additional 3 patients died after 24 hours this past year which were also reviewed at the Pediatric Trauma Quality Management Committee and care was deemed appropriate

ACH Major Trauma Statistics (ISS>12) 2012/2013

31

APPENDIX B Major Trauma Statistics for 2012/2013

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 Disposition from the Emergency Department Diagnostic Imaging Statistics Day of Week and Time of CT Non-Operative Procedures Performed in 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

2008/2009 2009/2010 2010/2011 2011/2012 2012/2013 Total Patients

74 83 83 90 76

Males

49 66.2%

55 66.3%

53 63.9%

57 63.3%

48 63.1%

Females

25 33.8%

28 33.7%

30 36.1%

33 36.7%

28 36.8%

Total Length of Stay (LOS) (days)

1052 956 1046 812 502

Median LOS

5 4 6 5 4

Mean LOS

14 12 13 9 7

Total Emergency Department (ED) LOS (hours)

277.1 328.4 328.8 397.6 318.4

Median ED LOS (hours)

4.1 3.7 4.0 3.4 3.4

Mean ED LOS (hours)

4.7 4.4 4.6 4.9 4.1

ICU Admissions

29 39.2%

36 43.4%

36 43.4%

37 41.1%

25 32.8%

Median ICU LOS (days)

4 2 2 1 2

Mean ICU LOS (days)

6.7 10 4 4 4

Total ICU LOS (days)

193 352 160 163 90

Median ISS

20 17 17 16 23

Mean ISS

22.8 20 21 21 23

Direct Admits

15 8 11 7 4

Referrals to ACH from other centres

33 44.6%

30 36.1%

36 43.4%

40 44.4%

31 40.8%

Deaths 2 2.7%

8 9.7%

5 6%

4 4.4%

5 6.6%

In 2012/2013, 76 major trauma patients (meeting criteria for inclusion in the trauma

registry) were seen at the ACH. This volume is slightly lower than the five-year average of 81 major trauma patients seen annually. This 2012/2013 trauma volume represents 8.4% of all patients admitted to the ACH with injuries (n=905), which is a 1.6% decrease from last year.

As seen in previous years, the percentage of major trauma patients who are males (63.1%) continues to be greater than females, which is consistent with the five-year average of 65%.


33

Major trauma patients referred in from other centers represented 40.8% of the major trauma volume for 2012/2013. This is consistent with the five-year average of 42%.

Length of stay for major trauma patients ranged between 1 and 120 days. Mean LOS of 7 days is lower than the five-year trend of 11. Median LOS of 4 days is slightly lower than the five-year trend of 5.

The total ED LOS was 318.4 hours, and lower than the five-year average of 330 hours. Both the mean and median LOS were consistent with the five-year averages of 4.5 and 3.7 respectively.

32.8% of major trauma patients were admitted to the ICU, which is lower than the five-year average of 40.0%. Total ICU LOS was 90 days, which is significantly lower than the five-year average of 192. The mean ICU LOS is lower than the five-year average of 5.7 and the median is consistent at 2.

Both the mean (23) and median (23) ISS for major trauma patient from 2012/2013 were higher than the five-year averages of 21.6 (mean) and 18.6 (median).

A total of 5 deaths were seen in major trauma patients in 2012/2013. This represents 6.6% of major trauma volume, and is slightly higher than the five-year average of 5.8%.


34

Figure 1. Age and Gender Distribution for ACH Major Trauma Patients for 2012/2013

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

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

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


35

2. Etiology of Injuries Mechanism of Injury describes the nature of the injury, such as transportation, falls, violence, and other mechanisms of injury. Figure 3. Breakdown by Mechanism of Injury

Figure 3 shows the breakdown of the mechanism of injuries for the incidents in 2012/2013 as compared to the historical trend. This past year there were decreases in violence and other mechanisms.


36

Mechanism of Injury – Transportation Figure 4. Transportation Statistics

Figure 4 shows the breakdown of transportation-related injuries in 2012/2013 as compared to the historical trend. There was an increase in MVC as well as water-related injuries this past year with a significant decrease in pedestrian injuries. A total of 20 patients (26% of major trauma patients) were involved in transportation-related incidents in 2012/2013.

Mortality: 10% 2 patients died. ISS ranged from 13 to 50. Mean ISS was 27 and median ISS was 26.

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

Figure 5 shows the 13% decrease in transportation-related incidents from 2011/2012 to 2012/2013. Note the significant decrease over the past five years – this may be attributed to Injury Prevention campaigns geared towards car seats and booster seats.


37

Figure 6. Transportation by Age Group

Figure 6 shows the breakdown of transportation incidents by age groups in 2012/2013 as compared to the historical trend. Significant changes to all age groups can be seen.

In 2012/2013: Age Group <1 (n=0, 0%) No patients in this age category. Age Group 1-4 (n=3, 15%) included 1 pedestrian, 1 bicyclist and 1 ATV related injury. Age Group 5-9 (n=5, 25%) included 3 passengers, 1 pedestrian and 1 non-pedestrian non-

passenger. There was one death in the age group. Age Group 10-14 (n=7, 35%) included 3 passengers, 3 bicyclists and 1 ATV related injury.

There was one death in this age group. Age Group > 14 (n=5, 25%) included 3 drivers, 1 passenger and 1 water-craft related injury


38

Mechanism of Injury – Falls Figure 7. Statistics for Falls as the MOI Figure 7 shows the breakdown of falls incidents in 2012/2013 as compared to the historical trend.

A total of 28 patients (37% of major trauma patients) were admitted for fall-related injuries.

Mortality: 4% one patient died. ISS ranged from 13 to 38. Mean ISS was 20 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 31%.


39

Figure 9. Falls by Age Group

Figure 9 shows the breakdown of fall incidents by age groups in 2012/2013 as compared to the historical trend. A significant increase seen in the 1-4 yr old age group is due to the increased number of upper level window falls. Public service campaigns are done by AHS Emergency Medical Services in May of each year to help prevent this.

In 2012/2013: Age Group <1 (n=5, 18%) all were multi-level falls, 4 of these patients fell while being carried. Age Group 1-4 (n=9, 32%) included 4 multi-level falls, 4 falls out of buildings and 1 fall into a

hole. There was one death in this age group. Age Group 5-9 (n=6, 22%) included 3 multi-level falls, 2 same level falls and 1 fall on stairs or

steps. Age Group 10-14 (n=5, 19%) included 3 same level falls and 2 falls from buildings and other

structures. Age Group >14 (n=3, 11%) included 1 same level fall, 1 fall while playing sports and 1

other/unspecified fall.


40

Mechanism of Injury – Violence Figure 10. Violence as the MOI Figure 10 shows the breakdown of violence-related incidents in 2012/2013 as compared to the historical trend. Note that the majority were caused by assault with an object.

A total of 5 patients (7% of major trauma patients) were admitted for violence-related injuries.

Mortality: 0% all patients survived. ISS ranged from 16 to 32. The mean ISS was 21. The median ISS was 16.

Figure 11. Five-Year Trend for Violence as the MOI Figure 11 shows the significant decrease in violence related injuries over the past 4 years – there has been a decrease in non-accidental or intentional trauma cases.


41

Figure 12. Violence Incidents by Age Group

Figure 12 shows the breakdown of violence incidents by age groups in 2012/2013 as compared to the historical trend. Note the large increase of 10-14 yr olds as well as the > 14 yr olds with the subsequent decrease in the 1 to 9 age groups.

Age Group <1 (n=1, 20%) 1 non-accidental or intentional injury in this age category. Age Group 1-4 (n=0, 0%) No patients in this age category. Age Group 5-9 (n=0, 0%) No patients in this age category. Age Group 10-14 (n=3, 60%) included 1 assault with and object, 1 unarmed assault and 1

non-accidental or intentional injury. Age Group >14 (n=1, 20%) included 1 assault with an object.


42

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

Figure 13 shows the breakdown of other mechanism of injuries in 2012/2013 as compared to the historical trend. There were no fire & explosion related injuries this year. A total of 23 patients (30% of major trauma patients) were admitted for other mechanism of injuries.

Mortality: 9% 2 patients died. ISS ranged from 13 to 42. For survivors, the mean ISS was 22 and the median ISS was 25. For non-survivors, the mean ISS was 25 and median ISS was 25.

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

Figure 14 shows an 11% increase 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.


43

Figure 15. Other Mechanism by Age Group

Figure 15 shows the breakdown of incidents involving other mechanism of injury by age groups in 2012/2013 as compared to the historical trend. There was an increase in 5-9 yr olds and 10-14 yr olds. In 2012/2013: Age Group <1 (n=1, 4%) included 1 striking against and object. Age Group 1-4 (n=6, 26%) included 1 foreign body ingestion, 2 striking against objects , 1

asphyxiation resulting in death, 2 struck accidentally by objects or persons and 2 submersion injuries with 1 resulting in death.

Age Group 5-9 (n=6, 26%) included 1 animal related injury, 2 struck accidentally by objects or persons,1 sports related injury, 1 asphyxiation and 1 mechanical injury.

Age Group 10-14 (n=9, 39%) included 3 animal related injuries, 1 submersion injury, 1 asphyxiation and 4 sports related injuries.

Age Group >14 (n=1, 4%) included 1 sports related injury.


44

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 2012/2013. Blunt injuries comprised 97% of major trauma population. This has been consistent over the past 5 years as seen in figure 17 below. Of note, on April 1, 2012 all AHS trauma centers began capturing data on all penetrating traumas regardless of ISS in the Alberta Trauma Registry. At ACH during the 2012/2013 fiscal year there were 8 penetrating traumas with ISS <12. Figure 17. Five-Year Trend for Type of Injury

Figure 17 compares the different types of injuries from 2008/2009 up to 2012/2013.


45

Place of Injury Figure 18. Statistics for Place of Injury

Figure 18 shows where the patients were injured in 2012/2013 as compared to the historical trend. Discussion with the patients and families while in the hospital has decreased the unspecified place of injury percentage.


46

3. Referrals and Emergency Management Referral Patterns

Out of 406 major trauma patients from 2008/2009 to 2012/2013, a total of 170 patients (42%) 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 25 patients (15% of total referrals) and Red Deer Regional Hospital with a total of 17 patients (10% of total referrals) over five years.

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 2008/2009 2009/2010 2010/2011 2011/2012 2012/2013 Total Region 1 - Chinook Health Region, Total = 37 Blairmore - Crowsnest Pass 1 1 Cardston – Municipal 1 1 2 1 5 Lethbridge Regional 4 1 7 6 7 25 Picture Butte Municipal 1 1 Pincher Creek Municipal 1 1 2 Taber H.C.C. 1 2 3 Region 2 - Palliser Health Region, Total = 17 Bassano General 1 1 2 Brooks Health Centre 1 1 2 Medicine Hat Regional 3 3 3 2 2 13 Region 3 - Calgary Health Region, Total = 51 Banff - Mineral Springs 1 1 1 4 1 8 Calgary – Foothills 8 4 1 2 1 16 Calgary - General/Peter Lougheed 2 2 3 2 1 10 Calgary – Rockyview General 2 1 3 Claresholm General 1 1 2 Didsbury - Mountain View H.C. 1 1 2 High River General 1 2 1 4 Strathmore - Valley General 1 1 1 3 Vulcan General 1 1 Cochrane Urgent Care 1 1 Okotoks Urgent Care 1 1


47

Region 4 - David Thompson Health Region, Total = 35 Drumheller Regional 2 1 1 4 Innisfail H.C.C. 1 1 Red Deer Regional 3 5 2 4 3 17 Olds General 1 1 2 Sundre General 4 1 1 6 Stettler General 2 2 Three Hills H.C.C. 1 1 Rocky Mountain House 1 1 Hanna H.C.C 1 1 Other Alberta Hospitals, Total = 3 University of Alberta Hospital 1 1 1 3 British Columbia, Total = 17 Cranbrook Regional Hospital 2 3 1 6 Fernie District Hospital 1 1 2 Golden & District General Hospital 2 1 3 Invermere District Hospital 2 1 1 1 5 Salmon Arm, Shuswap Hospital 1 1 Nova Scotia, Total = 1 Cape Breton 1 1 Saskatchewan, Total = 6 Lloydminster General 1 2 3 Maidstone Union Hospital 1 1 Royal University Hospital, Saskatoon 1 1 Regina 1 1 Out of Country, Total = 3 Montana 1 1 Egypt 1 1 Mexico 1 1


48

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 2012/2013 as compared to the historical trend. Note the slight decrease in helicopter transports for direct from the scene patients.

Figure 20. Referrals

Figure 20 shows the patients who were referred to ACH for further treatment in 2012/2013 as compared to the historical trend. Note the increase in air 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.


49

Figure 21. Ground vs Air

Ground ambulance transported 48 patients (63%) of major trauma patients in 2012/2013, which is slightly lower than the previous fiscal year. Their ISS was a mean of 23 and median of 20. Figure 21 also shows the increase in the use of air transport by 5% in 2012/2013. Patients transported by air had an ISS mean of 27 and median of 25. Month and Time of Arrival Figure 22. Month of Arrival

There was an increase in major trauma patients arriving in ACH ED in April, July, December and January in 2012/2013 as compared to the historical trend. Note the significant decrease in major trauma patients in September, October, November and March as compared to the previous years.


50

Figure 23. Day of Arrival

In 2012/2013, there was an increase in major trauma patients arriving in ACH-ED on Tuesdays, Wednesdays and Thursdays. The other days were less busy in 2012/2013 compared to the previous years, with the largest drop on Mondays and Saturdays. Time of Arrival Figure 24. Time of Arrival

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


51

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.This is an important indicator that will be monitored as most of the support services used by major trauma patients are on-call and therefore potentially not in-house during these hours.

Diagnostic Imaging Performed in 2012/2013 Table 3. Diagnostic Imaging A total of 56 patients (74% of major trauma patients) went urgently to CT for imaging of the following body locations. In addition 1 patient went to CT non-urgently. This is consistent with the 5 year average of 72% for urgent CTs for major trauma patients.

Diagnostic Imaging CT Locations

# Patients Percent of Total Patients (n=56)

Head 40 71% Abdomen 29 52% Pelvis 26 46% Chest 8 14% Spine 21 38% Face 6 11%

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


52

Figure 27. Time of Day of Urgent CT

Figure 27 compares the time of urgent CTs from 2008/2009 to 2012/2013. 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 2012/2013, 50% (n=28) of patients who went to CT had CTs done from 16:01 to midnight. Only 23% of patients had CT’s from midnight to 8:00 AM, and 27% of patients had CT’s from 08:01 to 16:00.

Figure 28. Day of the Week CT performed

Figure 28 compares the day of the week CT was performed from 2008/2009 to 2012/2013. In 2012/2013 there is an increase in the CT’s performed on Wednesday and Thursday with a significant decrease on Saturday and Sunday – both of which were also the days noted to have a decrease in arrival of major trauma patients.


53

Non-Operative Procedures Performed in 2012/2013 Table 4. Non-operative Procedures Performed on Patients while in ACH ED

Non-Operative Procedures # Patients Percent of Total Patients (n=72)

Gastric Tube Insertion 14 19% Foley Catheter Insertion 23 32% Intubation 8 11% Blood Product Administration 5 7% Chest Tube Insertion 2 3%

Patient Disposition from ED Figure 26.

Figure 26 shows the breakdown of patient disposition from the ED in 2012/2013 as compared to the historical trend. This past year, there was a significant increase in patients that were sent to the ward with a significant decrease of direct admissions when compared to the past five years. There were two deaths in the ED in 2012/2013.


54

4. In-Patient Care Management and Outcomes Surgical Procedures Table 5. Five-Year Trend 2008/2009 2009/2010 2010/2011 2011/2012 2012/2013 Total Major Trauma Patients 74 83 83 90 76 Total Patients Requiring Surgery 21 24 25 30 20 Total OR Visits 34 46 40 54 25 Total OR Hours 91 112 106 162 42 Mean (hours per case) 4.3 4.7 4.2 5.4 2.1 Mean (visits per case) 1.6 1.9 1.6 2.0 1.0

In 2012/2013 20 (26%) of trauma patients went to the OR. This is slightly below the 5 year average of 29%. Note the total OR hours were significantly less this past year. Figure 29. Total Patients Requiring Surgery

Table 6. OR Data by Service

OR Data by Service - 2012/2013

Physician Service # of Procedures Neurosurgery 5 Orthopedics 6 Pediatric General Surgery 6 Plastics 4 ENT 3

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.


55

Figure 30. Time of Day to OR

Figure 30 compares the time patients went to the OR from 2008/2009 to 2012/2013. In 2012/2013, the majority of patients went to OR during their regular working hours, between 08:01-16:00. Length of Stay Statistics Figure 31. Patient LOS

Figure 31 compares the LOS of patients from 2008/2009 to 2012/2013. In 2012/2013, the median LOS for all patients is 4 days - consistent with the previous 5 year average of 5 days. A majority of patients (89%) stayed between 1 and 12 days, while 8% of patients stayed between 13 and 202 days.


56

Admitting Physician Service Analysis – 2012/2013 Table 7.

In 2012/2013, a total of 22 patients (30%) were initially admitted to ICU. Those patients were subsequently transferred to the following:

4 patients went to Neurosurgery 4 patients went to Pediatrics 10 patients went to General Surgery 3 died in ICU 1 patient was transferred to another acute care facility.

* Note that three patients were admitted to General Surgery, Neurosurgery and Orthopedics initially and then transferred to ICU for management of care.

Physician Service # Patients Initially

Admitted to Service

Percent of Total

Patients Admitted

n=74 (2 died in ED)

# Patients Transferred to Service

Total Trauma Cases

per Service

Total Days on Service

Mean LOS on Service

Median LOS on Service

ICU 22 30% 3* 25 90 4 2 Neurosurgery 12 16% 4 16 35 2 2

Orthopedics 2 3% 1 3 11 4 1 Pediatrics 8 10% 4 12 148 11 3 General Surgery 30 41% 10 41 224 5 4


57

Hospital Discharge Destination Figure 32. Discharge Destinations

Figure 32 shows that more patients went home with support services in 2012/2013 as compared to the historical trend. Outcomes by Age Figure 33. Survivors

Figure 33 compares all age groups of survivors.


58

Figure 34. Non-Survivors

Figure 34 shows 5 deaths in 2012/2013. Outcomes by ISS Figure 35. Survivors vs Non-Survivors by ISS

Most survivors (62%, n=44) had ISS from 16 to 25. Non-survivors were in the ISS range 16-25 with 5% mortality rate, ISS 26-35 with 13% mortality rate and ISS range 36-45 with 25% mortality rate.


59

TRISS Pre Charts for 2012/2013 The following charts identify patients according to their probability of survival (Ps). Each patient is characterized by the Revised Trauma Score (RTS) and the Injury Severity Score (ISS) and then plotted on a graph. The shaded area represents the combination of the RTS and the ISS which yield a probability of survival (Ps) of >.50. The area above the line represents a probability of survival of <.50. Patients who are above the shaded area and survive and those who die and are plotted in the shaded area are atypical cases and subject to medical review. The age groups are standard age groups used in the development of the TRISS analysis. Figure 36. Pediatric Pre Charts include blunt and penetrating mechanisms for patients < 15 years. Pediatric AIS 90 Coding

Report generated on 09/07/2013

Range From 01/04/2012 to 31/03/2013 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 + ...............L................. + 4 U | .................................... | M + ...................................... + A | ......................................... | 5 + ........................................... + 5 S | ............................................. | C + ...............L................................ + O | .................................................. | R 6 + ...............L................L.................... + 6 E | ....................................................... | + .......................................................... + | ............................................................ | 7 + ...............L..........L.L................................. + 7 | ................................................................. | + ............L..L.L......LLL........................................ + | ............LL.LL.LL....L...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: Pediatric AIS 90 Coding No Unexpected Survivors: Pediatric AIS 90 Coding

There were no unexpected deaths for patients less than 15 years in 2012/2013 using the TRISS methodology.


60

Figure 37. Adult Pre Charts include blunt and penetrating mechanisms between 15 and 17 years. Adult Blunt (15 - 54) AIS 90 Coding

Report generated on 09/07/2013

Range From 01/04/2012 to 31/03/2013 Query is A_R_ISS

1 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 + +---+----+----+----+----+----+----+----+----+----+----+----+----+----+----+ + | | 0 + + 0 | | + + | .. | 1 + .... + 1 | ....... | R + ......... + E | ............ | V 2 + .............. + 2 I | ................ | S + ................... + E | ..................... | D 3 + ........................ + 3 | .......................... | T + ............................. + R | ............................... | A 4 + ................................. + 4 U | .................................... | M + ...................................... + A | ......................................... | 5 + ........................................... + 5 S | ............................................. | C + ................................................ + O | .................................................. | R 6 + ..................................................... + 6 E | ....................................................... | + .......................................................... + | ............................................................ | 7 + .............................................................. + 7 | ................................................................. | + ................................................................... + | ............L..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 2012/2013 using the TRISS methodology.

ALBERTA CHILDREN’S HOSPITAL PEDIATRIC · PDF fileALBERTA CHILDREN’S HOSPITAL . PEDIATRIC ... introduction of Advanced Trauma Life Support ... Program held its first annual offering

Documents