alberta children’s hospital pediatric · pdf filealberta children’s hospital ....

1

ALBERTA CHILDREN’S HOSPITAL

PEDIATRIC TRAUMA PROGRAM

ANNUAL REPORT

2013 – 2014

ACH Trauma Program Staff

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

Sharleen Luzny ........................................................ 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 2013-2014 was one of growth and continued strength for our trauma program. Over that past few years we have worked to implement the recommendations made in the 2010 Trauma Association of Canada Accreditation and as a result of these changes and the hard work of the team our trauma system continues to provide exceptional care to the children of Southern Alberta. The Pediatric Trauma Program continues to collaborate on many provincial and national projects through the Provincial Trauma Committee of Alberta, the Interdisciplinary Trauma Network of Canada and the Trauma Association of Canada (TAC). Of note, our Pediatric Trauma Coordinator, Ms. Sherry MacGillivray, is the current co-chair for the Pediatric Committee of TAC. Over the past few years the trauma program has submitted funding proposals to support a dedicated on-call TTL program. Unfortunately this initiative has not yet been funded. Although we feel that a dedicated on-call TTL program would provide optimal care to the trauma patients seen at ACH, we continue to improve our current system. We currently have 4 designated trauma shifts throughout the day with a designated trauma physician whose first priority is the management of any trauma patients presenting to the ACH ED. The improved flow and increased physician coverage has allowed the trauma physician to be freed of other clinical responsibilities while they dedicate their attention to the trauma patient. In 2013-2014, 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); and outreach education to referral centres by partnering with KidSIM™, the Pediatric Human Patient Simulation Program at ACH. Due to the success and high enrollment of the ATLS course offered at ACH in 2012, another dedicated ACH ATLS course was not required this year. ATLS courses are still regularly available in Calgary and throughout the province through the ATLS program. 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 for their continued support of our simulation educational initiatives. 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”.

4

On a personal note, Dr. Jonathan Guilfoyle would like to extend a heartfelt thank you to all the members of the Trauma Program Committee for their hard work and dedication. Above all, he would like to thank Ms. Sherry MacGillivray for her tireless efforts and unwavering commitment to our trauma program. Trauma Committee members 2013-2014: Surgical Services: Dr. Steven Lopushinsky, Dr. Mary Brindle, Michelle Noble, Lisette Lockyer, Dr. William Hyndman Orthopedics: Dr. Carmen Brauer, Dr. Fabio Ferri de Barros Anesthesiology / OR: Dr. Jeremy Luntley, Dr. Brian Kuwahara, Dr. Nancy Ghazar, Debra Harris, Rob Catena, Robin Thorvaldson PICU / Transport: Dr. Eli Gilad, Anita Hadley Neurosurgery: Dr. Clare Gallagher, Dr. Walter Hader Diagnostic Imaging: Dr. Deepak Kaura, Dr. Cathy Chrusch Emergency: Dr. Marc Francis, Suzanne Wickware Injury Prevention: Diane Jaeger, Katie McGillivray, Valerie Cook Rehabilitation: Conny Betuzzi Social Work: Kathy Lyons

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. Ongoing education by multiple ACH educators is done annually. Special thanks to Kelly Bullivant, NP for extra teaching this past year.

ii) Pediatric In-patient Trauma Service

• A dedicated in-patient trauma service, to provide and direct the primary clinical care of multiple 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 2013-2014.

iii) Trauma Tertiary Survey • The Pediatric Trauma Tertiary Survey 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, held by Lisette Lockyer, was re-evaluated, resulting in a dedication to trauma patients only. Ms Lockyer also runs an outpatient follow up Trauma Clinic.

v) Trauma Team Activation Guidelines (Code 77) • A Code 77 is activated by a nurse in the Emergency Department for

major trauma patients using specific guidelines that include physiological, anatomical and mechanism of injury. The guidelines were reviewed and ‘tightened up’ in July 2013 which resulted in less overall activations and less ‘overcall’ of the trauma team. 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%. See Appendix B for 2013-2014 details.

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 2013-2014 completion rate was 91%, which is an increase from last year.

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

Trauma Coordinators developed a provincial nursing trauma record to be used in all emergency departments and urgent care centers in the province. This record was felt to be an important standardization of trauma care and management. It was initiated in July 2012 and was revised in the fall of 2013 with the new revision released in January 2014.

ix) Pediatric Massive Transfusion Protocol

• The Pediatric Massive Transfusion Protocol is available for use for all patients in ACH. These activations are evaluated in partnership with Transfusion Medicine. Additionally, there are 2 units of O negative pRBCs in the ED trauma room for immediate use.

x) Trauma ‘No Refusal’ Policy

• An ACH ‘No Refusal’ Policy for pediatric trauma patients was endorsed by the Pediatric Trauma Committee in 2010. It states that no pediatric trauma patient in the ACH catchment area will be refused or turned away from our facility. This is the case even when there are no ICU or in-patient beds available. Under those circumstances, patients will be accepted and stabilized in the ED at ACH while further disposition is arranged.

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

xii) ACH Trauma Manual

• The ACH Trauma Manual is for new residents and staff physicians, as well as other disciplines working with trauma patients. It was revised in February 2013 and will continue to be revised as necessary by the Trauma Committee.

xiii) Liaising with Regional, Provincial and National Groups

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

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

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

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

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

8

3. Education

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

• April 25, 2013 - Dr. Jonathan Guilfoyle “Trauma M & M”

• May 23, 2013 - Dr. Natalie Yanchar “Pediatric Trauma Systems and Systematic Pediatric Trauma Care”

• September 26, 2013 - Dr. Willem Meeuwisse “The Zurich Consensus on Concussion in Sport”

• October 24, 2013 - Dr. Walter Hader “ACH Imaging Guidelines”

• November 28, 2013 - Dr. Shabnam Minoosepehr “Trauma M & M”

• January 23, 2014 - Dr. Elaine Gilfoyle “The Trauma Team – its More than just the ABC’s”

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

ii) Trauma Nursing Core Course • The Trauma Nursing Core Course (TNCC) continues to be held at

ACH twice per year. This course is designed for nurses caring for patients in any part of the trauma spectrum and has international recognition.

iii) Mock/Just-in-Time Trauma Codes

• These 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) 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 2013-2014:

April 2013 Didsbury, Strathmore May 2013 Medicine Hat, Vulcan June 2013 Rocky Mountain House Sept 2013 Wetaskiwin, Tofield, South Health Campus Calgary Oct 2013 Airdrie, Banff, Lethbridge, Claresholm Nov 2013 Red Deer, Pincher Creek, Crowsnest Pass March 2014 Strathmore, Black Diamond,

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

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

vi) Nursing Trauma Simulation Sessions

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

vii) Advanced Trauma Procedural Skills Lab • Through the collaboration of the Trauma Program and the ECMO

program at ACH this attending-focused lab allowed participants to practice advanced procedures including chest tube insertion, emergent thoracotomy and surgical airways. It was held in May 2013 with plans to make it a semiannual event. Special thanks to Dr. S. Lopushinsky and Dr. M. Brindle for their assistance.

viii) Emergency Medicine for Rural Hospitals (Banff AB - Jan 2014) • “Tips and Tricks for Procedural Interventions for Pediatric Patients” –

Sherry MacGillivray

10

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

Ness, Dr. A. Wilmott, Dr. J. Guilfoyle, Sherry MacGillivray

x) 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.

11

4. Research The following research projects were in progress or completed during 2013-2014:

PUBLICATIONS:

1) Russell K, Meeuwisse WH; Nettel-Aguirre A, Emery CA, Wishart

J, Romanow N, Rowe BH, Goulet C, Hagel BE. Characteristics of injuries sustained by snowboarders in a terrain park. Clinical Journal of Sport Medicine May 2013;23(3):p 172–177

2) Beres A, Wales PW, Christison-Lagay ER, McLure ME, Fallat ME, Brindle ME. Non-operative management of high-grade pancreatic trauma: is it worth the wait? Journal of Pediatric Surgery May 2013;48(5):919-23

3) Hagel BE, Romanow N, Morgunov N, Embree T, Couperthwaite AB, Voaklander D, Rowe BH. Do visibility aids reduce the risk of motor-vehicle collision or hospitalization in bicyclists? Accident Analysis & Prevention 2014,65:85-96

4) Hagel BE, Yanchar NL. Bicycle helmet legislation to increase helmet use and reduce head injury risk. Position Statement submitted to the Canadian Paediatric Society Injury Prevention Committee: Paediatrics & Child Health, November 2013; 18(9): 475-486

5) 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, 2013;59: 206-212

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

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

8) Romanow N, 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 2013;19:5 336-341 Doi:10.1136/injuryprev-2012-040500

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

http://journals.lww.com/cjsportsmed/pages/currenttoc.aspx�

12

IN PROGRESS:

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

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

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

N, Rowe BH, Goulet C, Hagel BE. Comparing the characteristics of snowboarders injured in a terrain park who present to the ski patrol, the emergency department or both. Accepted: International Journal of Injury Control and Safety Promotion

3) Russell K, Meeuwisse WH, Nettel-Aguirre A, Emery CA, Gushue S,

Wishart J, Romanow N, Rowe BH, Goulet C, Hagel BE Listening to a personal music player and odds of injury among snowboarders in a terrain park: a case-control study. Accepted: British Journal of Sports Medicine

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

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

5) Pandya A, MacGillvary S, McKee J, Guilfoyle J, Joffe A, Thompson GC

Traumatic Brain Injury and Sepsis in Children Admitted to Hospital Following Major Trauma. American Academy of Pediatrics, San Diego Oct 2014, European Congress on Emergency Medicine, Amsterdam, Holland Sept 2014

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 2013-2014 are summarized in Appendix A. Pre-ACH care:

1. Presence of pre-hospital documentation from any phase of patient transport. 2. GCS < 8 at scene with mechanical airway intervention. 3. Length of stay at rural hospital > 2 hours. 4. Injury time to Trauma Center (TC) < 4 hours (for transferred patients). 5. Utilization of ACH Transport team for transfer.

Resuscitative care: 6. Trauma Team Activation. 7. Direct admission (bypassed the Emergency Department (ED)). 8. GCS <8 at the TC with mechanical airway intervention. 9. Presence of ED nursing documentation every 30 minutes. 10. Presence of sequential neurological documentation in the ED for suspected head/spinal

cord injuries. 11. Hypothermic in the ED (< 35.0˚C). 12. GCS < 12 in the TC with a CT head performed within 4 hours from trauma center arrival

(TCA). 13. Patient stay in the ED less than 4 hours.

Definitive care: 14. Admission to a surgeon or intensivist. 15. Craniotomy within 4 hours after TCA with unstable epidural/subdural hematoma. 16. Missed cervical spine injury after 48 hours from TCA without maintaining spinal

precautions. 17. Any laparotomy procedure performed. 18. Femur fracture to the OR within 24 hours from TCA. 19. Open long bone fracture to the OR within 6-12 hours from TCA (depending on the

severity of #). 20. Unplanned return to the OR within 48 hours of initial procedure. 21. Missed injuries identified after 48 hours from TCA. 22. Reduction of joint dislocation/fracture dislocation after 1 hour from TCA. 23. Revascularization of an ischemic limb within 6 hours from the time of injury. 24. ORIF of facial fractures within 7 days after injury. 25. Operative repair of spinal fractures within 7 days after injury. 26. Pelvic ring fracture/acetabular fracture (with hemodynamic instability) provisional

stabilization > 6 hours from TCA. 27. Definitive treatment of displaced acetabular fracture > 7 days from TCA. 28. Unplanned PICU admission or re-admission.

Outcome: 29. Death during the first 24 hours from TCA. 30. Did the patient die in ACH?

14

6. Future Planning The 2014-2015 year will focus on the following activities: • Continue to optimize the functioning of our Trauma Team Leader Program • Continuing to focus on quality Pediatric Trauma Education • Continuing advocacy of injury prevention initiatives • Continuing leadership on a regional, provincial and national level • Continuing an active pediatric trauma research program • Continuing excellence in quality assurance leadership • Focusing on improving communication with all of the services impacted in

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

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

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.

ACH Trauma Quality Indicators (ISS >12) 2013/2014

15

Appendix A Alberta Children’s Hospital Trauma Quality Indicators for 2013/2014 Pre-ACH Care: 1. Presence of pre-hospital documentation from any phase of patient transport.

Are all pre-hospital ambulance reports from all phases of patient transport present on the medical record? Exclusions: Inappropriate where patients arrived by private vehicle, walk-ins, and unknown how patient arrived at hospital. Unknown: missing PCR. Inclusions: n = all patients with pre-hospital care provider(s).

Indicator Yes No

2013/2014, n = 80 79 1 2012/2013, n = 62 62 0 2011/2012, n = 77 71 6 2010/2011, n = 66 61 5 2009/2010, n = 69 65 4

Cooperation with Alberta Health Services EMS since Nov 2011 allows on-line record access which has improved the compliance of this indicator tremendously. However, obtaining out of province pre-hospital documentation is still challenging at times. 2. Glasgow Coma Scale (GCS) < 8 at scene with mechanical airway intervention.

Did the patient with a first recorded scene GCS < 8 receive mechanical airway intervention at the scene? Mechanical airway includes: oral intubation, nasal intubation, tracheostomy, and cricothyroidotomy. It does not include nasopharyngeal airway, laryngeal mask (LMA) or oropharyngeal airway. Exclusions: Inappropriate - patients with unknown GCS, patients without prehospital care, intubated patients prior to GCS calculation. Inclusions: n = all patients with first recorded GCS ≤ 8 at the scene.

Indicator Yes No 2013/2014, n = 19 5 14 2012/2013, n = 10 5 5 2011/2012, n = 11 2 9 2010/2011, n = 6 3 3 2009/2010, n = 5 2 3 Pediatric experts advise that it is best practice to move the injured pediatric patient from the scene quickly to acute care for intubation, if required, rather than attempt intubation at the scene. EMS protocols are being reviewed to have LMA insertion as first attempt rather than endotracheal tube intubation. This change has not yet been formalized, but could account for the high number

94

92 92

100

99

6 8 8

1

2009/2010 2010/2011 2011/2012 2012/2013 2013/2014

%Yes %No

40 50 18

50 26

60 50 82

50 74

2009/2010 2010/2011 2011/2012 2012/2013 2013/2014

%Yes %No


16

of non-intubated patients this past year. All patients are reviewed at the Pediatric Trauma Quality Management Committee to ensure appropriate care was given. 3. Length of stay (LOS) at rural hospital greater than two hours.

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

Indicator Yes No 2013/2014, n = 37 27 10 2012/2013, n = 28 19 9 2011/2012, n = 33 20 13 2010/2011, n = 35 24 11 2009/2010, n = 25 16 9

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

Did the patient arrive at a trauma centre < 4 hours from the time of injury? Trauma Centre is defined as ACH, FMC, U of A or Stollery Hospitals in Edmonton. As well as Red Deer, Lethbridge or Medicine Hat Hospitals. Exclusions: Out of the patient transfers, 6 patients were transferred from within Calgary, 5 from Lethbridge, 4 from Red Deer and 3 from Medicine Hat resulting in a total (n= 24) 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.


A high number of patients are still not seen at a Trauma Centre within the 4 hour timeline. Many factors contribute to delays, however, most are found to be related to challenges in mobilizing transfer of patients from rural health centers. The further progression of RAAPID (Referral, Access, Advice, Placement, Information & Destination) protocols, which started in 2011, has helped mobilize transport more efficiently. This has been a priority for the Provincial Trauma Committee. Of note, this past year there were 4 patients that had delayed presentation at a rural center as well as 2 further patients that were treated at two difference rural centres. All patients are reviewed at the Pediatric Trauma Quality Management Committee and communication regarding means of transport is given back to RAAPID if indicated.

64 69 61 68 73

36 31 39 32 27

2009/2010 2010/2011 2011/2012 2012/2013 2013/2014

%Yes %No

22 23 41 23

25

78 77 59 46

75

2009/2010 2010/2011 2011/2012 2012/2013 2013/2014

%Yes %No


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 2013/2014, n = 43 13 30

2012/2013, n = 31 7 24

2011/2012, n = 42 9 33

2010/2011, n = 40 13 27

2009/2010, n = 31 5 26

The Alberta Children’s Hospital offers a specialized Pediatric Transport Team Service, which transports critically ill or injured children from referral centers located in southern Alberta, south-eastern British Columbia, and south-western Saskatchewan. The transport team travels by ambulance, helicopter or fixed-wing aircraft and provides quality pediatric critical care to the residents of these areas who do not otherwise have access to pediatric critical care specialists. Through RAAPID, medical control and mobilization of the team is achieved via the PICU attending physician. The team consists of a respiratory therapist (RT) and an ACH ED or PICU registered nurse (RN), with a physician on call for difficult cases. Stabilization, if possible, is achieved prior to returning back to ACH, thus making the previous two indicators of ‘rural hospital LOS’ and ‘time to trauma centre’ longer on some occasions.

16 33 21 23 30

84 68 79 77 70

2009/2010 2010/2011 2011/2012 2012/2013 2013/2014

%Yes %No


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 guidelines were reviewed and ‘tightened up’ in July 2013 which resulted in less overall activations and less ‘overcall’ of the trauma team. The above graph illustrates Code 77 activation for the major trauma population only (ISS > 12). In some cases, the trauma team may be called however the patient does not meet the Trauma Registry inclusion criteria. In the past year, the total Code 77 activations for all patients (regardless of ISS) was 126 (compared to an average of 139 prior to the 2013 changes). Overcall (those not admitted) was 38%. Undercall (those that should have had an activation according to guidelines) was 2%. The over and undercall of Code 77 patients is monitored closely by the Pediatric Trauma Coordinator and reported monthly at the Trauma Committee. 7. Direct Admission - Bypassed the Emergency Department (ED)

Direct Admission Exclusions: ED deaths Inclusions: n = all patients who were admitted to the trauma centre.


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, one was directly admitted with injuries older than 24 hours. Two were sent from the Foothills Medical Centre (FMC) (adult trauma centre in Calgary): one to the trauma unit once

10 13 8 5 6

90 87 92 95 94

2009/2010 2010/2011 2011/2012 2012/2013 2013/2014

%Yes %No

3 2

4

2

4 5

3

1 1 1

3 2

8

5

7

9 10

8

10

6 7

4

9

7

4 4 4

6 5

2

0

2 1

2 3

2

4 5

7

5 5 4

6

2

6

1

3

1

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

# of

Act

ivat

ions

Major Trauma Team Activation

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


19

the age was determined; and one sent post operatively. One patient was seen by an ACH pediatric emergency physician at the new South Health Campus in Calgary and sent for admission to the trauma unit. The remaining two were discussed at the Pediatric Trauma Quality Management Committee and should have stopped in the ED. 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

2013/2014, n = 5 5 0

2012/2013, n = 2 2 0

2011/2012, n = 0 0 0

2010/2011, n = 2 2 0

2009/2010, n = 4 3 1

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

2013/2014, n = 89 35 54

2012/2013, n = 72 34 38

2011/2012, n = 83 30 53

2010/2011, n = 71 25 46

2009/2010, n = 75 31 44

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.

75 100

0

100 100

25

0 2009/2010 2010/2011 2011/2012 2012/2013 2013/2014

%Yes %No

42 35 37 47 39

58 65 63 53 61

2009/2010 2010/2011 2011/2012 2012/2013 2013/2014

%Yes %No


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

2013/2014, n = 79 61 18

2012/2013, n = 59 44 15

2011/2012, n = 65 47 18

2010/2011, n = 64 44 20

2009/2010, n = 62 38 24

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

2013/2014, n = 88 3 85

2012/2013, n = 67 2 65

2011/2012, n = 79 1 78

2010/2011, n = 72 2 70

2009/2010, n = 72 1 71

These three hypothermic patients were actively rewarmed in the ED appropriately.

61 69 72 75 77

39 31 28 25 23

2009/2010 2010/2011 2011/2012 2012/2013 2013/2014

%Yes %No

1 3 1 3 3

99 97 99 97 97

2009/2010 2010/2011 2011/2012 2012/2013 2013/2014

%Yes %No


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

2013/2014, n = 19 19 0

2012/2013, n = 14 14 0

2011/2012, n = 14 13 1

2010/2011, n = 11 11 0

2009/2010, n = 12 12 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

2013/2014, n = 89 46 43

2012/2013, n = 72 40 32

2011/2012, n = 81 40 41

2010/2011, n = 72 35 37

2009/2010, n = 75 39 36

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. This past year, the Pediatric Trauma Quality Management Committee made recommendations for one trauma patient that had a long ED LOS.

100 100

93

100 100

7

2009/2010 2010/2011 2011/2012 2012/2013 2013/2014

%Yes %No

52 49 49 56 52

48 51 51 44 48

2009/2010 2010/2011 2011/2012 2012/2013 2013/2014

%Yes %No


22

Definitive care: 14. Admission to a surgeon or intensivist.

Was the patient admitted to a surgeon or an intensivist at the ACH trauma centre? Exclusions: ED deaths. Inclusions: n = all patients admitted to ACH Trauma Centre.

Indicator Yes No

2013/2014, n = 93 85 8

2012/2013, n = 74 66 8

2011/2012, n = 89 82 7

2010/2011, n = 82 76 6

2009/2010, n = 83 77 6

7 of the 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: 4 for isolated head injuries less than one year of age; and 2 for work up of non-accidental or intentional injuries. The remaining patient was reviewed at the Pediatric Trauma Quality Management Committee and recommendations were made. 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

2013/2014, n = 7 5 2

2012/2013, n = 3 2 1

2011/2012, n = 3 3 0

2010/2011, n = 4 4 0

2009/2010, n = 6 6 0

This past year, 2 patients had acute epidural hematomas that were taken to the OR just outside of the 4 hours. Both were discussed at the Pediatric Trauma Quality Management Committee, as well as M & M rounds, where recommendations were made.

93 93 92 89 91

7 7 8 11 9

2009/2010 2010/2011 2011/2012 2012/2013 2013/2014

%Yes %No

100 100 100 67 71

33 29

2009/2010 2010/2011 2011/2012 2012/2013 2013/2014

%Yes %No


23

16. Missed cervical spine injury after 48 hours from TCA without maintaining spinal precautions.

Did the patient have a missed c-spine injury with spinal precautions removed at the ACH trauma centre? Exclusions: ED deaths. Inclusions: n = all patients admitted to ACH Trauma Centre.

Indicator Yes No

2013/2014, n = 93 3 90

2012/2013, n = 74 0 74

2011/2012, n = 89 0 89

2010/2011, n = 82 0 82

2009/2010, n = 83 0 83

In this past year, there were 3 patients with missed c-spine injuries. All patients were discussed at the Pediatric Trauma Quality Management Committee and recommendations were made. One patient had an insignificant injury found outside the 48 hour time frame. The remaining two patients had been sent home post spinal clearance with injuries found more than 3 weeks later in follow up appointments – fortunately neither had neurological deficits because of these missed injuries. 17. Any laparotomy procedure performed.

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

Indicator Yes No

2013/2014, n = 95 2 93

2012/2013, n = 76 2 74

2011/2012, n = 90 4 86

2010/2011, n = 83 4 79

2009/2010, n = 83 4 79

The small number of laparotomies performed this past year remains consistent with historical trends and continues to show the conservative management philosophy in pediatrics in regards to abdominal trauma.

3

100 100 100 100 97

2009/2010 2010/2011 2011/2012 2012/2013 2013/2014

%Yes %No

5 5 4 3 2

95 95 96 97 98

2009/2010 2010/2011 2011/2012 2012/2013 2013/2014

%Yes %No


24

18. Femur fracture to the OR within 24 hours of TCA.

Did the patient have operative management of the femur fracture within 24 hours of arrival at ACH trauma centre? Exclusions: No femur fracture or no surgical intervention planned. Inclusions: n = all patients requiring operative management of femur fracture.

Indicator Yes No

2013/2014, n = 3 3 0

2012/2013, n = 4 4 0

2011/2012, n = 7 6 1

2010/2011, n = 4 3 1

2009/2010, n = 6 6 0

Note that the total n femur fracture is for ISS > 12 patients only. 19. Open long bone fracture to the OR after 6-12 hours from TCA (depending on the severity of the fracture).

Did the patient with open long bone fracture have operative management performed within 6 hours (grade 3) or 12 hours (grade 1, 2) of arrival to ACH trauma centre? The long bones include the radius, ulna, humerus, tibia, femur and fibula. Exclusions: No open long bone fractures; patients with open long bone #s but too unstable for operative repair within the timeframe; patients with open long bone #s who died within the timeframe. Inclusions: n = all patients requiring operative management of open fracture where grade of fracture is known.

Indicator Yes No

2013/2014, n = 0 0 0

2012/2013, n = 1 1 0

2011/2012, n = 2 1 1

2010/2011, n = 1 1 0

2009/2010, n = 0 0 0

100 75

86 100 100

25 14

2009/2010 2010/2011 2011/2012 2012/2013 2013/2014

%Yes %No

0

100

50

100

100

50

0

2009/2010 2010/2011 2011/2012 2012/2013 2013/2014

%No %Yes


25

20. Unplanned return to the OR within 48 hours of initial procedure.

Did the patient have an unplanned return to the operating room at the ACH trauma centre? Exclusions: No operating room visit. Inclusions: n = all patients with at least one operating room visit.

Indicator Yes No

2013/2014, n = 27 0 27

2012/2013, n = 20 1 19

2011/2012, n = 30 0 30

2010/2011, n = 34 0 34

2009/2010, n = 43 2 41

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

2013/2014, n = 93 4 89

2012/2013, n = 74 1 73

2011/2012, n = 89 0 89

2010/2011, n = 82 0 82

2009/2010, n = 82 1 81

A trauma tertiary survey (TTS) performed by the Trauma Surgery NP, Fellow or Resident at 24 hours after admission to the trauma centre helps to keep missed injuries to a minimum. This past year all four patients had a TTS – one patients’ injury was found on this survey and one was suspected. All were reviewed at the Pediatric Trauma Quality Management Committee and recommendations were made.

5 5

95 100 100 95 100

2009/2010 2010/2011 2011/2012 2012/2013 2013/2014

%No %Yes

1 1 4

99 100 100 99 96

2009/2010 2010/2011 2011/2012 2012/2013 2013/2014

%Yes %No


26

22. Reduction of joint dislocation/fracture dislocation after 1 hour from TCA.

If the patient had a joint dislocation or fracture dislocation (hip, shoulder, knee, elbow), was it reduced within first hour of TCA. Exclusions: No joint dislocation, died within first hour, wrist or ankle dislocations. Inclusions: n = all patients with joint dislocation or fracture dislocation who survived at least 1 hour.

Indicator Yes No

2013/2014, n = 0 0 0

2012/2013, n = 1 0 1

2011/2012, n = 3 2 1

2010/2011, n = 0 0 0

2009/2010, n = 2 2 0

23. Revascularization of an ischemic limb within 6 hours from the time of injury.

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

Indicator Yes No

2013/2014, n = 0 0 0

2012/2013, n = 0 0 0

2011/2012, n = 0 0 0

2010/2011, n = 0 0 0

2009/2010, n = 0 0 0

100

0

67

0 0

33

100

0 2009/2010 2010/2011 2011/2012 2012/2013 2013/2014

%Yes %No

0 0 0 0 0

2009/2010 2010/2011 2011/2012 2012/2013 2013/2014

%Yes %No


27

24. ORIF of facial fractures within 7 days of injury.

Did the patient with a facial fracture go to the operating room at ACH trauma centre within 7 days of injury? Exclusions: No major facial fractures or died prior to repair. Inclusions: n = all patients requiring operative management of major facial fractures who survive at least 7 days.

Indicator Yes No

2013/2014, n = 1 1 0

2012/2013, n = 3 3 0

2011/2012, n = 1 0 1

2010/2011, n = 1 1 0

2009/2010, 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

2013/2014, n = 2 2 0

2012/2013, n = 0 0 0

2011/2012, n = 0 0 0 2010/2011, n = 1 1 0

2009/2010, n = 0 0 0

100 100 100

100

0

100

2009/2010 2010/2011 2011/2012 2012/2013 2013/2014

%Yes %No

0

100

0 0

100

2009/2010 2010/2011 2011/2012 2012/2013 2013/2014

%Yes %No


28

26. Pelvic ring fracture / acetabular fracture (with hemodynamic instability) provisional stabilization > 6 hours of TCA.

If the patient had an operative repair of pelvic fractures, was it completed > 6 hours after arrival? Exclusions: No operative repairs or patient hemodynamically stable. Inclusions: n = all patients with operative repair of pelvic fractures with hemodynamic instability.

Indicator Yes No

2013/2014 n = 0 0 0

2012/2013 n = 0 0 0

2011/2012 n = 0 0 0

2010/2011, n = 0 0 0

2009/2010, n = 2 0 2

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

2013/2014 n = 0 0 0

2012/2013 n = 0 0 0

2011/2012 n = 1 0 1

2010/2011, n = 0 0 0

2009/2010, n = 1 1 0

100 0 0 0 0

2009/2010 2010/2011 2011/2012 2012/2013 2013/2014

%Yes %No

100

0 0

100

0

2009/2010 2010/2011 2011/2012 2012/2013 2013/2014

%Yes %No


29

28. Unplanned PICU admission or re-admission.

Did the patient have an unplanned admission to ICU at the ACH trauma centre? Exclusions: ED deaths. Inclusions: n = all patients admitted to ACH Trauma Centre.

Indicator Yes No

2013/2014, n = 93 2 91

2012/2013, n = 74 2 72

2011/2012, n = 89 1 88

2010/2011, n = 82 2 80

2009/2010, n = 82 0 82

This year two patients needed to be transferred to the PICU from the trauma unit due to patient deterioration and instability. The PICU Specialized Transitional Educational Personnel (STEP) team 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

2013/2014, n = 39 0 39

2012/2013, n = 24 0 24

2011/2012, n = 36 3 33

2010/2011, n = 36 1 35

2009/2010, n = 36 0 36

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

2 1 1 2

100 98 99 99 98

2009/2010 2010/2011 2011/2012 2012/2013 2013/2014

%Yes %No

3

100 97 100 100 100

2009/2010 2010/2011 2011/2012 2012/2013 2013/2014

%Yes %No


30

Outcome: 29. Death during the first 24 hours of TCA.

Did the patient die within the first 24 hours of admission to the ACH trauma centre? Exclusions: All patients who survived. Inclusions: n = all patients who died.

Indicator Yes No

2013/2014, n = 5 3 2

2012/2013, n = 5 2 3

2011/2012, n = 4 3 1

2010/2011, n = 5 3 2

2009/2010, n = 8 4 4

Unfortunately 3 patients died in the ACH ED and PICU within 24 hours this past year: One post submersion; one with a spinal cord injury; and the third from multiple injuries. See Appendix B for mechanism details. 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

2013/2014, n = 95 5 90

2012/2013, n = 76 5 71

2011/2012, n = 90 4 86

2010/2011, n = 83 5 78

2009/2010, n = 83 8 75

Two additional patients with head injuries died after 24 hours this past year. See Appendix B for mechanism details. They were also reviewed at the Pediatric Trauma Quality Management Committee and care was deemed appropriate

50 60 75

40 60

50 40 25 60

40

2009/2010 2010/2011 2011/2012 2012/2013 2013/2014

%Yes %No

10 6 4 7 5

90 94 96 93 95

2009/2010 2010/2011 2011/2012 2012/2013 2013/2014

%Yes %No

ACH Major Trauma Statistics (ISS>12) 2013/2014

31

APPENDIX B Major Trauma Statistics for 2013/2014

1. General Overview Age Gender

2. Etiology of Injuries Mechanism of Injury Type of Injury Place of Injury

3. Referrals and Emergency Management Referrals from Health Regions Mode of Transportation to ACH Ground vs Air Transport ED Arrival By Month, Day and Time of Arrival 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

2009/2010 2010/2011 2011/2012 2012/2013 2013/2014 Total Patients

83 83 90 76 95

Males

55 66.3%

53 63.9%

57 63.3%

48 63.1%

57 60.0%

Females

28 33.7%

30 36.1%

33 36.7%

28 36.8%

38 40.0%

Total Length of Stay (LOS) (days)

956 1046 812 502 765

Median LOS

4 6 5 4 5

Mean LOS

12 13 9 7 8

Total Emergency Department (ED) LOS (hours)

328.4 328.8 397.6 318.4 402.9

Median ED LOS (hours)

3.7 4.0 3.4 3.4 3.5

Mean ED LOS (hours)

4.4 4.6 4.9 4.1 4.3

ICU Admissions

36 43.4%

36 43.4%

37 41.1%

25 32.8%

39 41.0%

Median ICU LOS (days)

2 2 1 2 2

Mean ICU LOS (days)

10 4 4 4 3

Total ICU LOS (days)

352 160 163 90 125

Median ISS

17 17 16 23 19

Mean ISS

20 21 21 23 24

Direct Admits

8 11 7 4 6

Referrals to ACH from other centres

30 36.1%

36 43.4%

40 44.4%

31 40.8%

43 45.2%

Deaths 8 9.7%

5 6%

4 4.4%

5 6.6%

5 5.2%

In 2013/2014, 95 major trauma patients (meeting criteria for inclusion in the trauma registry) were

seen at the ACH. This volume is higher than the five-year average of 85 major trauma patients seen annually. This 2013/2014 trauma volume represents 11.2% of all patients admitted to the ACH with injuries (n=844), which is a 2.8% increase from last year.


33

As seen in previous years, the percentage of major trauma patients who are males (60%)

continues to be greater than females, which is consistent with the five-year average of 63.3%. Major trauma patients referred in from other centers represented 45.2% of the major trauma

volume for 2013/2014. This is consistent with the five-year average of 42%. Length of stay for major trauma patients ranged between 1 and 56 days. Mean LOS of 8 days is

lower than the five-year trend of 10. Median LOS of 5 days is consistent with the five-year trend of 5. The total ED LOS was 402.9 hours, and higher than the five-year average of 355.2 hours. Both

the mean and median LOS were consistent with the five-year averages of 4.5 and 3.6 respectively. 41.0% of major trauma patients were admitted to the ICU, which is consistent with the five-year

average of 40.3%. Total ICU LOS was 125 days, which is significantly lower than the five-year average of 178. The mean ICU LOS is lower than the five-year average of 5.7 and the median is consistent at 2.

Both the mean (24) and median (19) ISS for major trauma patient from 2013/2014 were higher

than the five-year averages of 21.8 (mean) and 18.4 (median). A total of 5 deaths were seen in major trauma patients in 2013/2014. This represents 5.2% of

major trauma volume, and is slightly lower than the five-year average of 6.4%.


34

Figure 1. Age and Gender Distribution for ACH Major Trauma Patients for 2013/2014

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). In the past, the eventual assumption of this age group was a priority for the ACH Pediatric Trauma Program. However due to capacity issues and surgical funding, assuming this age group is no longer a priority. This past year the ACH ED RN answering the EMS patch phone has been re-directing these patients to the FMC ED if Trauma Team Activation - Code 77 criteria is met.

8 9

18 20

2

6 7

12 12

1

0

5

10

15

20

25

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

# of

Pat

ient

s

Age Groups

Male Female

2009/2010 2010/2011 2011/2012 2012/2013 2013/2014

ACH 10 7 8 10 3

FMC 29 24 27 22 37

PLC 0 0 0 0 0

RGH 0 0 0 0 0

0

5

10

15

20

25

30

35

40

# of

Pat

ient

s

15 to 17 year olds Major Trauma Patients


35

2. Etiology of Injuries

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

. Figure 3 shows the breakdown of the mechanism of injuries for the incidents in 2013/2014 as compared to the historical trend. This past year there was an increase in transport related injuries.

Transport 41%

Falls 27%

Violence 6%

Other 26%

2007/2008 - 2011/2012

Transport 44%

Falls 28%

Violence 10%

Other 18%

2013/2014

Transport 32%

Falls 31% Violence

10%

Other 27%

2009/2010 - 2012/2013


36

Mechanism of Injury – Transportation Figure 4. Transportation Statistics

Figure 4 shows the breakdown of transportation-related injuries in 2013/2014 as compared to the historical trend. Note: MRV is motorized recreational vehicle. A total of 42 patients (44% of major trauma patients) were involved in transportation-related incidents in 2013/2014.

Mortality: 7% 3 patients died. ISS ranged from 13 to 75. Mean ISS was 27 and median ISS was 24.

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

Figure 5 shows a five year average high for 2013/2014 as well as the 18% increase in transportation-related incidents from 2012/2013 to 2013/2014.

34% 29%

39%

26%

44%

0%

10%

20%

30%

40%

50%

2009/2010 2010/2011 2011/2012 2012/2013 2013/2014

% o

f Pat

ient

s

Years

MOI -Transportation

MVC 45%

Pedestrian 19%

Cyclist 26%

MRV 10%

2013/2014

MVC 43%

Pedestrian 22%

Cyclist 25%

MRV 8%

Water 1%

Railway 1%

2009/2010-2012/2013


37

Figure 6. Transportation by Age Group

Figure 6 shows the breakdown of transportation incidents by age groups in 2013/2014 as compared to the historical trend. Significant changes to all age groups can be seen.

In 2013/2014: Age Group <1 (n=0, 0%) No patients in this age category. Age Group 1-4 (n=7, 17%) included 2 pedestrians, 3 bicyclists and 2 passengers. There were 2

deaths in this age group. Age Group 5-9 (n=16, 38%) included 5 passengers, 6 pedestrians, 1 snowmobile and 4 ATV related

injuries. Age Group 10-14 (n=17, 40%) included 2 drivers, 4 passengers, 3 bicyclists, 4 pedestrians and 4

ATV related injuries. There was one death in this age group. Age Group > 14 (n=2, 5%) included 1 cyclist and 1 passenger.

<1 0%

1 to 4 17%

5 to 9 38%

10 to 14

40%

>14 5%

2013/2014

<1 4% 1 to 4

11%

5 to 9 26% 10 to

14 46%

>14 13%

2009/2010 - 2012/2013


38

Mechanism of Injury – Falls Figure 7. Statistics for Falls as the MOI Figure 7 shows the breakdown of falls incidents in 2013/2014 as compared to the historical trend. There has been a significant increase in multi-level falls which includes: falls from second story windows, falls while being carried, falls off horses and falls from playground equipment.

A total of 27 patients (28% of major trauma patients) were admitted for fall-related injuries.

Mortality: 0% all patients survived. ISS ranged from 12 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 below the five year average of 31%.

Multi-Level 89%

Same-Level 11%

2013/2014

Multi-Level 75%

Same-Level 19%

Other and Unspecified

6%

2009/2010 - 2012/2013

29% 33%

30%

37%

28%

0%

5%

10%

15%

20%

25%

30%

35%

40%

2009/2010 2010/2011 2011/2012 2012/2013 2013/2014

% o

f Pat

ient

s

MOI Falls


39

Figure 9. Falls by Age Group

Figure 9 shows the breakdown of fall incidents by age groups in 2013/2014 as compared to the historical trend. A significant increase is seen in the <1 yr old and 5 - 9 yr old age groups.

In 2013/2014: Age Group <1 (n=10, 37%) 9 multi-level falls and 1 fall on same level. 5 of the patients with multi-

level falls fell while being carried. Age Group 1-4 (n=5, 18%) included 3 multi-level falls, 1 fall out of buildings and 1 fall on stairs. Age Group 5-9 (n=7, 26%) included 2 multi-level falls, 1 same level falls, 2 falls out of buildings, 1 fall

from a ladder and 1 fall on stairs. Age Group 10-14 (n=5, 19%) included 4 multi-level falls and 1 fall on same level. Age Group >14 (n=0, 0%) no patients in this age category.

<1 37%

1 to 4 18%

5 to 9 26%

10 to 14 19%

>14 0%

2013/2014

<1 23%

1 to 4 25% 5 to 9

17%

10 to 14 29%

>14 6%

2009/2010 - 2012/2013


40

Mechanism of Injury – Violence Figure 10. Violence as the MOI Figure 10 shows the breakdown of violence-related incidents in 2013/2014 as compared to the historical trend. Note the significant increase in assault with object this past year.

A total of 9 patients (10% of major trauma patients) were admitted for violence-related injuries.

Mortality: 0% all patients survived. ISS ranged from 13 to 38. The mean ISS was 22. The median ISS was 25.

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

Other & Unspecified

56%

Assault with

object 44%

2013/2014

Unarmed Assault

17%

Self-Inflicted

8%

Other & Unspecified

69%

Assault with

Object 6%

2009/2010 - 2012/2013

16%

12%

8% 7% 9%

0%

5%

10%

15%

20%

2009/2010 2010/2011 2011/2012 2012/2013 2013/2014

% o

f Pat

ient

s

MOI - Violence


41

Figure 12. Violence Incidents by Age Group

Figure 12 shows the breakdown of violence incidents by age groups in 2013/2014 as compared to the historical trend. Note the large increase of <1 yr olds with the subsequent decrease in the 1 - 4 yr old age group.

Age Group <1 (n=5, 56%) All 5 were 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=1, 11%) included 1 assault with object. Age Group 10-14 (n=2, 22%) included 2 assaults with an object. Age Group >14 (n=1, 11%) included 1 assault with an object.

<1 56%

1 to 4 0%

5 to 9 11%

10 to 14 22%

>14 11%

2013/2014

<1 31%

1 to 4 33% 5 to 9

5%

10 to 14 17%

>14 14%

2009/2010 - 2012/2013


42

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

Figure 13 shows the breakdown of other mechanism of injuries in 2013/2014 as compared to the historical trend. There were no inhalation& ingestion, other & unspecified or fire & explosion related injuries this year. However, there was an increase in both animal and mechanical related injuries. A total of 17 patients (18% of major trauma patients) were admitted for other mechanism of injuries.

Mortality: 12% 2 patients died. ISS ranged from 16 to 45. For survivors, the mean ISS was 23 and the median ISS was 17. 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 6% decrease in the number of patients whose injuries are caused by animal, burn, inhalation, submersion injury, and mechanical-related incidents when compared to the last five years.

Animal 23%

Mechanical 71%

Submersion & Drowning

6%

2013/2014

Animal 14%

Mechanical 61%

Submersion & Drowning

14%

Inhalation & Ingestion

4%

Fire & Explosion

3%

Other & Unspecified

2%

2009/2010 - 2012/2013

22%

28%

23%

30%

18%

0%

5%

10%

15%

20%

25%

30%

35%

2009/2010 2010/2011 2011/2012 2012/2013 2013/2014

% o

f Pat

ient

s

MOI - Other


43

Figure 15. Other Mechanism by Age Group

Figure 15 shows the breakdown of incidents involving other mechanism of injury by age groups in 2013/2014 as compared to the historical trend. There was an increase in 5-9 yr olds and 10-14 yr olds. In 2013/2014: Age Group <1 (n=0, 0%) no patients in this age category. Age Group 1-4 (n=3, 18%) included 1 foreign body, 1 struck accidentally by object and 1 burn. There

was one death in this age category. Age Group 5-9 (n=6, 35%) included 2 animal related injuries, 3 struck accidentally by objects or

persons and 1 mechanical injury. Age Group 10-14 (n=8, 47%) included 2 animal related injuries,1 struck accidentally by falling object,

4 sports related injuries and 1 submersion injury. There was one death in this age group. Age Group >14 (n=0, 0%) no patients in this age category.

<1 0%

1 to 4 18%

5 to 9 35%

10 to 14 47%

>14 0%

2013/2014

<1 8%

1 to 4 30%

5 to 9 20%

10 to 14 31%

>14 11%

2009/2010 - 2012/2013


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 2013/2014. Blunt injuries comprised 95% of major trauma population. This has been consistent over the past 5 years as seen in figure 17.

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 both the 2012/2013 and 2013/2014 fiscal years there were a total of 9 penetrating traumas.

90

3 1 1 0

50

100

Blunt Penetrating Burn Other

Type of Injury - 2013/2014 Total Pts = 95


9 9

0

50

100

2012/2013 2013/2014

# of

Pat

ient

s

Fiscal Years

Penetrating Trauma All ISS


45

Figure 17. Five-Year Trend for Type of Injury

Figure 17 compares the different types of injuries from 2009/2010 up to 2013/2014. Place of Injury Figure 18. Statistics for Place of Injury

Figure 18 shows where the patients were injured in 2013/2014 which is fairly consistent with the historical trend. Note this past year there were no injuries that took place on a farm.

77 75 81

75

90

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

20

40

60

80

100

2009/2010 2010/2011 2011/2012 2012/2013 2013/2014

# o

Pati

ents

Fiscal Years

Type of Injury - Five Year Trend Total Pts = 427


Home/Res Inst 27%

Other 6%

Public Building

7%

Recreation 16%

Street 36%

Unspecified 8%

2013/2014

Farm 5%

Home/Res Inst 30%

Other 6%

Public Building

4%

Recreation 20%

Street 27%

Unspecified 8%

2009/2010 - 2012/2013


46

3. Referrals and Emergency Management Referral Patterns

Out of 427 major trauma patients from 2009/2010 to 2013/2014, a total of 180 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 26 patients (14% of total referrals) and Red Deer Regional Hospital with a total of 18 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 2009/2010 2010/2011 2011/2012 2012/2013 2013/2014 Total Region 1 - Chinook Health Region, Total = 41 Blairmore - Crowsnest Pass 1 2 3 Cardston – Municipal 1 2 1 3 7 Lethbridge Regional 1 7 6 7 5 26 Pincher Creek Municipal 1 1 2 Taber H.C.C. 1 2 3 Region 2 - Palliser Health Region, Total = 16 Bassano General 1 1 2 Brooks Health Centre 1 1 Medicine Hat Regional 3 3 2 2 3 13 Region 3 - Calgary Health Region, Total = 49 Banff - Mineral Springs 1 1 4 1 1 8 Black Diamond – Oilfields General 1 1 Calgary – Foothills 4 1 2 1 1 9 Calgary – General/Peter Lougheed 2 3 2 1 1 9 Calgary – Rockyview General 2 1 1 4 Calgary – South Health Campus 3 3 Canmore General 1 1 Claresholm General 1 1 1 3 High River General 1 2 1 4 Strathmore - Valley General 1 1 3 5 Cochrane Urgent Care 1 1 Okotoks Urgent Care 1 1


47

Region 4 - David Thompson Health Region, Total = 42 Didsbury – Mountain View H.C. 1 1 2 Drumheller Regional 2 1 1 4 Hanna H.C.C. 1 1 Innisfail H.C.C. 1 1 Olds General 1 1 2 Red Deer Regional 5 2 4 3 4 18 Rocky Mountain House 1 2 3 Stettler General 2 2 Sundre General 4 1 1 1 7 Three Hills H.C.C. 1 1 2 Other Alberta Hospitals, Total = 2 University of Alberta Hospital 1 1 2 British Columbia, Total = 22 Cranbrook Regional Hospital 2 3 1 5 11 Elkford Health Centre 1 1 Fernie District Hospital 1 1 3 5 Golden & District General Hospital 1 1 Invermere District Hospital 1 1 1 3 Salmon Arm, Shuswap Hospital 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 = 2 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 2013/2014 as compared to the historical trend. Note the slight increase 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 2013/2014 as compared to the historical trend. Note the increase in fixed wing 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.

Ground 61%

Helicopter 10%

Private/Walk-in

29%

2013/2014

Ground 63%

Helicopter 6%

Private/Walk-in

31%

2009/2010 - 2012/2013

Ground 56% Helicopter

16%

Fixed-wing 28%

2013/2014

Ground 61%

Helicopter 23%

Fixed-wing 13%

Private vehicle

3%

2009/2010 - 2012/2013


49

Figure 21. Ground vs Air

Ground ambulance transported 56 patients (59%) of major trauma patients in 2013/2014, which is slightly lower than the previous fiscal year. Their ISS was a mean of 24 and median of 19. Figure 21 also shows the increase in the use of air transport by 4% in 2013/2014. 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 May, June, July, August, December and February in 2013/2014 as compared to the historical trend. Note the significant decrease in major trauma patients in April, September, January and March as compared to the previous years.

0%

10%

20%

30%

40%

50%

60%

70%

2009/2010 2010/2011 2011/2012 2012/2013 2013/2014

Ground vs Air

Ground

Air

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

Mean 09/10 - 12/13 6.0 7.0 8.0 9.5 10.3 8.3 6.0 5.5 4.8 6.0 6.3 5.5

2013/2014 4 8 11 13 17 6 6 5 8 3 11 3

0.0 2.0 4.0 6.0 8.0

10.0 12.0 14.0 16.0 18.0

Comparison of ED Arrival by Month for 2013/2014 with 2009/2010 - 2012/2013


50

Figure 23. Day of Arrival

In 2013/2014, there was an increase in major trauma patients arriving in ACH ED on Tuesdays, Wednesdays, Fridays and Saturdays. The other days were less busy in 2013/2014 compared to the previous years, with the largest drop on Sundays. Time of Arrival Figure 24. Time of Arrival

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

Sun Mon Tues Wed Thu Fri Sat

Mean 09/10 - 12/13 17.0 9.8 8.3 11.0 10.8 14.0 12.3

2013/2014 14 9 9 12 9 17 25

0.0 2.0 4.0 6.0 8.0

10.0 12.0 14.0 16.0 18.0

Comparison of Arrival by Day for 2013/2014 with 2009/2010 - 2012/2013

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

Mean 09/10 -12/13 14.0 25.3 43.8

2013/2014 8 28 59

43%

10%

26%

0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0

Comparison of Time of Arrival for 2013/2014 with 2009/2010 - 2012/2013


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.

Diagnostic Imaging Performed in 2013/2014 Table 3. Diagnostic Imaging A total of 74 patients (78% of major trauma patients) went urgently (within 6 hours of arrival) to CT for imaging of the following body locations. This is consistent with the 5 year average of 73% for urgent CTs for major trauma patients.

Diagnostic Imaging CT Locations

# Patients Percent of Total Patients (n=74)

Head 51 69% Abdomen 48 65% Pelvis 44 59% Spine 38 51% Chest 19 26% Face 8 11%

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

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

Mean 09/10 - 12/13 3.5 19.8 25.5

2013/2014 1 21 30

71%

6%

15%

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

Comparison of Patients Arriving Directly From the Scene for 2013/2014 with 2009/2010 -2012/2013


52

Figure 26. Time of Day of Urgent CT

Figure 26 compares the time of urgent CTs from 2009/2010 to 2013/2014. Note the consistency that the majority of urgent CTs are performed between 16:01-24:00 which is when the majority of major trauma patients arrive at the ACH ED. In 2013/2014, 66% (n=49) of patients who went to CT had CTs done from 16:01 to midnight. Only 8% of patients had CT’s from midnight to 8:00 AM, and 26% of patients had CT’s from 08:01 to 16:00.

Figure 27. Day of the Week CT performed

Figure 28 compares the day of the week CT was performed from 2009/2010 to 2013/2014. In 2013/2014 there is a significant increase in the CT’s performed on Friday and Saturday with a decrease on Tuesday, Wednesday and Thursday.

4

18

34

8 13

37

9

18

41

13 15

28

6

19

49

0

10

20

30

40

50

60

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

# of

Pat

ient

s

Time of Day

Time of Day of Urgent CT (within 6 hours of arrival, n=74)

2009/2010 2010/2011 2011/2012 2012/2013 2013/2014

7 7 8 8 10

7 9

7

2 5

12 9

15

8

13

7 6 6 9

7

20

7 7 10 11

7

3

11 8

5 7 7

16

21

10

0

5

10

15

20

25

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

# of

Pat

ient

s

Day of the Week CT Performed

2009/2010 2010/2011 2011/2012 2012/2013 2013/2014


53

Non-Operative Procedures Performed in 2013/2014 Table 4. Non-operative Procedures Performed on Patients while in ACH ED

Non-Operative Procedures # Patients Percent of Total Patients (n=89)

Gastric Tube Insertion 12 13% Foley Catheter Insertion 19 21% Intubation 10 11% Blood Product Administration 4 4% Chest Tube Insertion 1 1%

Patient Disposition from ED Figure 28.

Figure 26 shows the breakdown of patient disposition from the ED in 2013/2014 as compared to the historical trend. This past year, there was a small decrease of direct admissions when compared to the past five years. There were two deaths in the ED in 2013/2014.

Died in ED 2%

ICU 31%

OR/ICU 6%

OR/Ward 2%

Direct Admit

6%

Ward 53%

2013/2014

Died in ED 1%

ICU 29%

OR/ICU 7%

OR/Ward 3% Direct

Admit 10%

Ward 49%

Died in OR 1%

2009/2010 -2012/2013


54

4. In-Patient Care Management and Outcomes Surgical Procedures Table 5. Five-Year Trend 2009/2010 2010/2011 2011/2012 2012/2013 2013/2014 Total Major Trauma Patients 83 83 90 76 95 Total Patients Requiring Surgery 24 25 30 20 27 Total OR Visits 46 40 54 25 31 Total OR Hours 112 106 162 42 80 Mean (hours per case) 4.7 4.2 5.4 2.1 2.7 Mean (visits per case) 1.9 1.6 2 1 1

In 2013/2014 27 (28%) of trauma patients went to the OR. This is consistent with the 5 year average of 29%. Note the total OR hours have increased significantly this past year as compared to 2012/2013, but below the 5 year average of 100. Figure 29. Total Patients Requiring Surgery

Table 6. OR Data by Service

OR Data by Service - 2013/2014

Physician Service # of Procedures Neurosurgery 13 Orthopedics 7 Pediatric General Surgery 5 Plastics 7 Gastrointestinal 1

Table 6 shows the physician services that performed the surgical procedures. During some procedures, there were multiple physician services in the OR at one time.

29% 30% 33% 26% 28%

0%

10%

20%

30%

40%

50%

2009/2010 2010/2011 2011/2012 2012/2013 2013/2014

# of

Pat

ient

s

Total Patients Requiring Surgery


55

Figure 30. Time of Day to OR

Figure 30 compares the time patients went to the OR from 2009/2010 to 2013/2014. In 2013/2014, 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 2009/2010 to 2013/2014. In 2013/2014, the median LOS for all patients was 5 days - consistent with the previous 5 year average of 5 days. A majority of patients (82%) stayed between 1 and 12 days, while 18% of patients stayed between 13 and 56 days.

4

10 10

5

12

8

1

12

17

2

14

4 2

16

9

0

5

10

15

20

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

Time of Day to OR

2009/2010 2010/2011 2011/2012 2012/2013 2013/2014

0%

10%

20%

30%

40%

50%

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

enti

le o

f Pat

ient

s

Number of Days

LOS by Percentile of Patients

2009/2010

2010/2011

2011/2012

2012/2013

2013/2014


56

Admitting Physician Service Analysis – 2013/2014 Table 7.

In 2013/2014, a total of 37 patients (40%) were initially admitted to ICU. Those patients were subsequently transferred to the following:

9 patients went to Neurosurgery 9 patients went to Pediatrics 14 patients went to General Surgery 3 died in ICU 1 patient was transferred to another acute care facility. 1 patient was discharged home.

* Note that two patients were admitted to Neurosurgery and Pediatrics initially and then transferred to ICU for management of care. Hospital Discharge Destination Figure 32. Discharge Destinations

Figure 32 shows that more patients went home with support services and to another acute care facility in 2013/2014 as compared to the historical trends. Documentation of destination has improved from the trauma unit.

Another Acute Care

Facility

Children's Aid/Foster

Care Died Home

Home with Support Services

Other Rehab Facility

Mean 09/10 -12/13 1 4 5.5 71.5 0.75 0 0.25

2013/2014 4 5 5 68 13 0 0

0 10 20 30 40 50 60 70 80

Comparison of Discharge Destination for 2013/2014 with 2009/2010 - 2012/2013

Physician Service # Patients Initially

Admitted to

Service

Percent of Total

Patients Admitted

n=93 (2 died in

ED)

# Patients Trans-

ferred to Service

Total Trauma Cases

per Service

Total Days

on Service

Mean LOS on Service

Median LOS on Service

ICU 37 40% 2* 39 125 3 2 Neurosurgery 15 16% 9 24 83 3 3 Orthopedics 1 1% 1 2 17 9 9 Pediatrics 8 9% 9 17 179 10 5 General Surgery 31 33% 14 45 362 8 6 Urology 1 1% 0 1 3 3 3


57

Outcomes by Age Figure 33. Survivors

Figure 33 compares all age groups of survivors. Figure 34. Non-Survivors

Figure 34 shows 5 deaths in 2013/2014.

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

Mean 09/10 - 12/13 10.6 16 14.8 27.8 8.3

2013/2014 15 12 30 30 3

0 5

10 15 20 25 30 35

Comparison of Survivors by Age Group for 2013/2014 with 2009/2010 - 2012/2013

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

Mean 09/10 - 12/13 0.75 3 0.75 0.5 0.5

2013/2014 0 3 0 2 0

0 0.5

1 1.5

2 2.5

3 3.5

Comparison of Non-Survivors for 2013/2014 with 2009/2010 - 2012/2013


58

Outcomes by ISS Figure 35. Survivors vs Non-Survivors by ISS

Most survivors (61%, n=58) had ISS from 16 to 25. Non-survivors were in the ISS range 16-25 with 40% mortality rate, ISS 36-45 with 40% mortality rate and ISS range 45+ with 20% mortality rate.

8

58

13 8

3 0 2 0 2 1 0

10

20

30

40

50

60

70

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

# of

Pat

ient

s

ISS

2013/2014

Survivors Non-Survivors


59

TRISS Pre Charts for 2013/2014 The following charts identify patients according to their probability of survival (Ps). Each patient is characterized by the Revised Trauma Score (RTS) and the Injury Severity Score (ISS) and then plotted on a graph. The shaded area represents the combination of the RTS and the ISS which yield a probability of survival (Ps) of >.50. The area above the line represents a probability of survival of <.50. Patients who are above the shaded area and survive and those who die and are plotted in the shaded area are atypical cases and subject to medical review. The age groups are standard age groups used in the development of the TRISS analysis. Figure 36. Pediatric Pre Charts include blunt and penetrating mechanisms for patients < 15 years. Pediatric AIS 90 Coding Report generated on 15/07/2014 Range From 01/04/2013 to 31/03/2014 Query is A_R_ISS 1 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 + +---+----+----+----+----+----+----+----+----+----+----+----+----+----+----+ + | | 0 + D + 0 | | + + | .. | 1 + .... + 1 | ....... | R + ......... + E | ............ | V 2 + .............. + 2 I | ................ | S + ................... + E | ..................... | D 3 + ........................ + 3 | .......................... | T + .........................L... + R | ............................... L | A 4 + ........................D........ + 4 U | .................................... | M + ...................................... + A | ......................................... | 5 + ........................................... L + 5 S | .............................L............... | C + ................................................ + O | .................................................. | R 6 + ..................................................... + 6 E | ....................................................... | + ...............L.......................................... + | ...............L.....................L...................... | 7 + ...............L.......LL..................................... + 7 | ................................................................. | + ............L..L........L...L...............L...................... + | ...........LLL.LLLL.L..LLL..L..L...L.L...D..L......................... | 8 + +---+----+----+----+----+----+----+----+----+----+----+----+----+----+----+ + 8 1 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 L = SURVIVOR(S) SHADED = Ps >= 0.50 D = DEATH(S) INJURY SEVERITY SCORE B = BOTH

There were 2 unexpected deaths and 2 unexpected survivors for patients less than 15 years in 2013/2014 using the TRISS methodology. Both deaths were reviewed by the Pediatric Trauma Quality Management Committee and care was deemed appropriate.


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 15/07/2014 Range From 01/04/2013 to 31/03/2014 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........LL............................................ | 8 + +---+----+----+----+----+----+----+----+----+----+----+----+----+----+----+ + 8 1 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 L = SURVIVOR(S) SHADED = Ps >= 0.50 D = DEATH(S) INJURY SEVERITY SCORE B = BOTH

There were no unexpected deaths for patients between 15 and 17 years in 2013/2014 using the TRISS methodology.

alberta children’s hospital pediatric · pdf filealberta children’s hospital ....

Documents