QUEEN ELIZABETH II HOSPITAL

REGIONAL TRAUMA PROGRAM

2015-2016

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Contents

Message from our Director …………………………………………………………………………………………………………………3

QEII Regional Trauma Program Overview ……………………………………………………………………………………………4

Executive Summary …………………………………………………………………………………………………………………………….4

QEII Regional Trauma Program Vision …………………………………………………………………………………………………5

QEII Regional Trauma Program Mission ………………………………………………………………………………………………5

QEII Regional Trauma Program Members ……………………………………………………………………………………………6

Current and Ongoing Initiatives …………………………………………………………………………………………………………..7

Quality Improvement ………………………………………………………………………………………………………………………….8

Data Registries …………………………………………………………………………………………………………………………………..10

Community ………………………………………………………………………………………………………………………………………..10

Future Planning ………………………………………………………………………………………………………………………….………10

Goal of this Report ……………………………………………………………………………………………………………………….…….11

Considerations …………………………………………………………………………………………………………………………….……..11 Trauma Patients by Age Range …………………………………………………………………………… …………………………….13

Gender and Average Age ………………………………………………………………………………………………….………………..14

Injury Type …………………………………………………………………………………………………………………………………………15

Resource Utilization …………………………………………………………………………………………………….……………. ………16

Mechanism of Injury ……………………………………………………………………………………………………….………………….17

ETOH Levels …………………………………………………………………………………………………………………… …………………18

Transport Related Injuries ………………………………………………………………………………………………………………….19

Fall Related Injuries ……………………………………………………………………………………………………………………………20

Interpersonal Violence ………………………………………………………………………………………………………………..…….21

Interpersonal Violence/Assault & Self Harm ………………………………………………………………………………………22

Mortality ……………………………………………………………………………………………………………………………………………23

Trauma Team Activation ……………………………………………………………………………………………………………………24

ED Arrival to O.R. (TTA/Yes vs TTA/No) ………………………………………………………………………………………….…..25 ED Arrival to CT (TTA/Yes vs TTA/No) …………………………………………………………………………………………….…..26

ED Arrival to ED Discharge (TTA/Yes vs TTA/No) …………………………………………………………….………….……….27 Time Spent in the ED ………………………………………………………………………………………………………………………….28

Elderly in the ED (Head Injury vs No Head Injury) ……………………………………………………………………………….29

Elderly in the ED (Time to CT) ……………………………………………………………………………………………………………..30

Definitions ………………………………………………………………………………………………………………………………………….31

List of Figures ……………………………………………………………………………………………………………………………………..33

List of Citations ……………………………………………………………………………………………………………………………………34

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Message from our Director

On behalf of the Queen Elizabeth II Hospital Regional Trauma Committee, we are pleased to

present the QEII Regional Trauma Report for 2015 through 2016. This report is the result of

countless hours of collecting trauma data from patient charts and related documentation on

trauma patients treated at the QEII Hospital.

The intent of this report is to highlight the work currently being done both at the regional level

and also as part of a provincial trauma system. We also examine ways in which we can optimize

the overall trauma care as part of that system.

Lastly, we would like to thank all the members of the Grande Prairie Regional Trauma Committee

and those involved in collecting and analyzing the data presented here. It is through this work

that we continue to develop and provide excellent care to our patients.

Any questions or comments are very welcome and can be forwarded to us directly.

Sincerely Johan Bolton MD, FRCSC

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QEII Regional Trauma Program

Emergency trauma care at the QEII strives to provide for the most critically ill and injured patients 24 hours a day, every day. Trauma is the number one cause of death among Canadians during the first four decades of life. This means that preventable injuries result in more deaths every year in our youngest and most vital population than all other causes of death within the same age range. Parachute Canada recently released a report stating that in 2010, 15,890 Canadians died as a result of preventable injuries. Based on the trends of past results, it is predicted that number will increase to an estimated 26,390 annually by the year 2035. Aside from the human cost of trauma, the Parachute Canada study shows that there is an increasing economic cost. The national total economic cost of trauma in 2010 was nearly $27 billion. That same year, Canada’s total population was approximately 34 million. Alberta has the highest cost per capita for preventable injuries in the country. Nationally, the total economic cost of preventable injury per person is $788. In Alberta, that cost is 1.4 times the national rate at $1,083 per capita. http://www.parachutecanada.org/downloads/research/Cost_of_Injury-2015.pdf

How does our region contribute to these numbers? Our catchment area covers a disproportionately large geographic area of Albert, including most of the northwest of the province and many remote communities in northeastern British Columbia. This report examines the data on the major traumas from our region who are treated at the Queen Elizabeth II Regional Hospital.

Executive Summary This report details the cause and outcomes of major trauma patients treated at the QEII Regional Hospital over a 2 year period, 2015 through 2016. Major traumas (ISS>12) (n=166), Minor penetrating traumas meeting the definition

(n=65) and Trauma Team Activations that did not meet criteria (n=10) giving a total of 241 patients (N=241) for this time period.

Most major trauma cases were the result of transport related injuries (n=89). Males account for 72% of all major traumas (n=119). The spring and summer months, April through September, see the highest volume of

major trauma (n=101).

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Friday and Saturday (n=43, n=40 respectively) have the highest number of traumas, as defined previously, and Wednesday (n=25) has the lowest volume.

The street (n=81) and home (n=68) are the most frequent places of injury. Most injured patients arrive directly from scene (n=173). Interpersonal injuries (assaults and self-inflicted) were over 21% of cases collected in the

registry (n=51). Work related injuries make up 8% (n=18) of trauma treated at the QEII. Post Emergency Department, 32% (n=77) were admitted to a ward while 31% (n=75) were

transferred to another acute care facility. Penetrating trauma data was collected starting in 2012 and include minor trauma as per

the definition. All penetrating trauma accounted for 32 % (n=76) during this collection period.

Trauma Team Activations criteria accounted for 24% (n=58). Elderly patients (≥ 60 years) made up 28% (n=47) of major trauma patients. Elderly patients with head trauma were 17% (n=28) of the major trauma population.

QEII Regional Trauma Program Vision: Utilizing an interdisciplinary team, we shall provide excellent, coordinated, and integrated trauma care to the people we serve in the North Zone of Alberta Health Services and surrounding area

QEII Regional Trauma Program Mission: Facilitate quality trauma care service consistent with the standard of care through and by;

• Integration of Services

• Inter-professional Care

• Continuum of Care (pre and inter hospital, primary acute care, secondary referral, and tertiary care, including transport)

• Timely – Right Care, Right Patient, Right Time

• Best Practices

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QEII Regional Trauma Program Members: Trauma Medical Director Dr. Johan Bolton Trauma Coordinator Lydia Megraw Trauma Manager Shelley Scorgie/Tracy Peddy (effective 2017) Trauma Data Analyst Karen Seymour

Trauma Program Medical Director

The Medical Director provides leadership and direction to the Grande Prairie Regional Trauma Program, which is based at the QEII Regional Hospital. The Director is a general surgeon who oversees all program activities that, impact the overall care of the trauma patient including clinical initiatives, education, data collection and research. The director leads a multidisciplinary team which strives to provide the best possible care and outcome for trauma patients within our region. The Trauma Coordinator and Data Analyst report to the Medical Director in areas of patient care, education and research.

Trauma Program Manager

Trauma Program Manager oversees the administrative, operational personnel and financial aspects of the program. The Trauma Coordinator and Data Analyst report to the Trauma Program Manager for administrative issues. The Program Manager also serves as an integral link between the Trauma Program and the regional AHS administration to facilitate the development and maintenance of internal clinical protocols and guidelines. The manager also serves as a liaison to hospital administration and clinical disciplines and assists with intra-facility and regional staff development.

Trauma Program Coordinator

The Trauma Program Coordinator is responsible for the implementation of the programming of the Grande Prairie Regional Trauma Program. This includes the development, implementation and evaluation of all of the initiative of the Trauma Program in Grande Prairie and the surrounding region. This includes the coordination of continuing education for health care providers at all levels of the trauma system. Key responsibilities include the fulfillment of regional and provincial strategies within the Trauma Program, as well as the organization of performance improvement initiatives and activities within the trauma system as a whole. The Coordinator is involved in facilitating protocol development within the Trauma Program and actively tracks trends in patient care through regular chart reviews.

Trauma Program Data Analyst

The Trauma Data Analyst fulfills several functions in the Trauma Program including the identification of trauma cases, analyzing and collecting the trauma data used in the building of the registry and the generation of various reports for research projects, publications and

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presentations. Further the Trauma Analyst is responsible for maintaining an accurate and current data registry which fosters data and indicator development for quality improvements in patient care and outcomes. Our current analyst is a member of TRISC (Trauma Registry Information Specialists of Canada), a national group which advocates for consistency in coding and data collection practices across the country while providing a forum for a team approach to problem solving, and for the sharing of expertise and skills. Trauma registry data is reported to and used by the Alberta Trauma Registry. Our data analyst is also responsible to analyze data and generate reports for the medical director, coordinator and manager when needed, including the development of the program’s annual report.

Current and Ongoing Initiatives

Education

The Grande Prairie Regional Trauma Program has regularly offered Advanced Trauma Life Support (ATLS) courses, over the past several years, for the physicians in our region. In conjunction with the ATLS course, a banquet is held and attended by course participants and other health care workers involved in the care of trauma patients. This is an educational and team building community activity that is always well attended. The Trauma Program supports the QEII Emergency Department orientation program; and ongoing “in-service” educational sessions. These sessions are led by the Trauma Coordinator, Emergency/ICU Educators, and Emergency & ICU Clinical Coordinators and focus on a broad range of emergency and trauma specific areas such as;

Trauma Nursing Core Course (TNCC)

Emergency Nursing Pediatric Course (ENPC)

Neonatal Resuscitation Program (NRP)

Advanced Cardiac Life Support Course (ACLS)

Pediatric Cardiac Life Support Course (PALS)

Cardiac Pulmonary Ressuscitation Course (CPR)

Canadian Triage Acuity Scale (CTAS)

Emergency Department Orientation Course

Trauma Team Activation (TTA) Guidelines

In an effort to bring the care of trauma patients at the QEII Hospital to the highest “best practice” standards, the Grande Prairie Regional Trauma Program initiated and formalized a multi–

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disciplinary Trauma Team, including members from the departments of Emergency, Surgery, Radiology, Laboratory, and Social Services. Specific criteria have been developed for the activation of the Trauma Team and the effectiveness of the system has been demonstrated by the data over the past many years, showing it to be one of the most effective in the province. Recently, a formalized system has been implemented for the activation of an Operating Room Trauma Team which allows for more OR staff to assist with major traumas being immediately taken to the OR. The Trauma Team was initiated August 3, 2011 and is regularly evaluated for process improvement purposes.

Massive Hemorrhage Protocol

The Trauma Program led the developlment of our local Massive Hemorrhage Protocol (MHP). The MHP was developed to ensure early administration of blood products when dealing with hemodynamically unstable patients undergoing massive blood loss. The MHP was implemented in 2014.

Trauma Distinction

Alberta Trauma Services, supported by Alberta Health Services (AHS), is currently involved in the Trauma Distinction process with Accreditation Canada. The QEII Regional Hospital is working towards receiving official designation as a Level III Trauma Facility as part of the provincial accreditation. The Trauma Program strives to develop and implement relevant trauma initiatives from the pre-hospital to the rehabilitation phase of trauma care in order to meet accreditation standards and become an improved trauma system.

Quality Improvement The Grande Prairie Regional Trauma Program has developed a formalized Performance Improvement Patient Safety (PIPS) program which involves reviewing flagged cases through a multi-disciplinary review sub-committee. As all trauma patient charts are tabulated for input into the database, specific filters identify cases which may be outside of the parameters set by both the Regional and Provincial programs. These standards include missed Trauma Team Activations, prolonged length of time to CT scanning, missed spinal precautions, and the length of time to be transferred out to a higher level of care. The Trauma Coordinator, with the assistance of the Data Analyst, filters each major trauma case in order to assess the type of trauma care we are

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providing. Through this process, our program can identify areas in need of review or improvement. As a result of these PIPS reviews, the Regional Trauma Program has been able to make recommendations and develop policies, procedures and/or guidelines that work towards improving the care provided in our region. The improvement of trauma care is continuous and ongoing and often leads the way for other subspecialties to follow. Over the past several years, the PIPS reviews have resulted in the development of new protocols and updates of others, including:

Spinal Immobilization and Spinal Precautions: Implemented in 2007 and 2011 respectively, with the goal of spinal immobilization to limit movement of the spine and prevent further harm as well as ensure proper positioning of a patient with known or suspected acute spinal injury.

Adult Trauma Admission Guidelines: Introduced 2013 and created to ensure adult trauma patients are admitted to the appropriate unit for their injuries.

Adult and Pediatric Trauma Standing Orders were updated to ensuring a standardized approach to trauma care.

Physician/Nursing Trauma Record: In 2011 the Alberta Trauma Coordinators, including the Grande Prairie Regional Trauma Coordinator, created a Provincial Nursing Trauma Record and an educational program to assist in its implementation. After a trial and review of this record it was recognized the provincial form did not meet all of the needs of the QEII’s emergency trauma team. Realizing that provincially guided record keeping does not always work best in a smaller regional setting, the Grande Prairie Regional Trauma Program, in collaboration with the Emergency Chief of Staff and the emergency department staff developed a specialized combined Physician/Nursing Trauma Record for use at the QEII Hospital emergency department. This unique record insured that all the data required for the provincial system was included but allowed for a more streamlined approach for a Level III Trauma facility. It was implemented in 2014 and continues to be successfully used.

EMS Patch Form: A new EMS patch form was created in 2013 to assist in identifying those inbound patients who may need specific services. The patch form allows staff to identify which criteria have been met and activate necessary staff for specific protocols accordingly. It was expanded to include other non-trauma patients and thus facilitated improved prehospital communication.

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Data Registries Building and contributing to the local registry is an ongoing process. Provincially, the Data Analysts have worked to become a more cohesive and collaborative group, in view of providing the most reliable data possible. As part of this process, the group performed review and rewriting of the Data Dictionary, coordinating the subsequent registry upgrade from individual servers to a web based system for the beginning of 2015. This initiative was led by the provincial epidemiologist at the direction of the Alberta Trauma Services Core Leadership Team. Our local Grande Prairie Data Analyst was a key player in the review and provided much needed leadership in the change process.

Community We continue to be involved with the Grande Prairie Safe Communities Program, taking an active role in injury prevention and education on a local level through various initiatives.

Future Planning

Safe Communities: Ongoing outreach to the community and its needs.

Pediatric Psych Consults: Identifying and providing support to patients and parents affected by trauma.

Operating Room Trauma Team Activation: Further strengthen the OR Trauma Team system now that concept has been approved. The need for this was recognized in late 2015. The activation parameters were determined and the policy is available for use in 2016.

Rounds: Starting in 2015, all staff and physicians have been invited to participate in Grande Rounds via telehealth presented by the Edmonton trauma program and pediatric trauma rounds from the Alberta Children’s Hospital.

SIMS: Trauma simulations were introduced in 2015 regular sessions being scheduled through the year.

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New Hospital: A new regional hospital with increased services and space is currently under construction with a planned opening in 2020.

Goal of this Report

• To examine the epidemiology of trauma patients meeting criteria for registry inclusion treated at the QEII Hospital.

• To disseminate information about trauma admissions at the QEII.

• To support the facilitation of injury and prevention/control programs.

• To increase awareness of injury as a major public health issue in the Peace Region.

• Highlight areas in which improvements have been achieved through the careful analysis of data, including areas of care which still need attentions.

Considerations This report provides data collected from the hospital charts of trauma patients who were determined to be victims of a major trauma with an Injury Severity Score (ISS) of greater than or equal to 12 and who were treated at the Queen Elizabeth II Regional Hospital, unless otherwise stated, from January 1, 2015 to December 31, 2016. This data set does not represent all people treated for trauma at the QEII Hospital and does not include the following:

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• People treated and or admitted with an ISS < 12 (with the exception of penetrating trauma as defined and Trauma Team Activations with ISS <12);

• People who die at scene; and • Trauma patients treated at other health care facilities within our region and then released.

The Injury Severity Score (ISS) is an internationally recognized scoring system developed to assign a level of severity to an injury or injuries. It is used in conjunction with the Abbreviated Injury Scale (AIS) which is the sum of the squares of the highest AIS score in each of the three most severely injured body regions. The ISS is scored from 1 to 75 with a higher score indicating increased severity. Injury reports are based on the primary cause of injury. Some percentages are rounded to the nearest whole number.

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Trauma Patients by Age Range

During 2015 through 2016 time period, there were a total of 241 (N=241) trauma patients treated at the

QEII and meeting criteria to be entered into the local and provincial trauma registries. A total of 166

(n=166) of those entered were Major Trauma or ISS≥12. In addition, 75 (n=75) Minor Trauma or ISS <

12 were entered into the registry to track the use of trauma resources; specifically, minor penetrating

traumas as defined by the ATR and minor Trauma Team Activations.

Figure 1

Major trauma, and those specific minor traumas collected, both have a spike in occurrences in the early

adult age range. There is also an interesting spike in major trauma in the age group(s) 51-60.

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Gender and Average Age

N=241

Figure 2

In keeping with provincial and national statistics, males are the victims of trauma the vast majority of

the time. In 2015-16, males accounted for 70% (n=169) of trauma with an average age of 42. Females

account for 30% (n=72) with and average age of 41.

“When based on gender, 2 out of every 3 injuries worldwide are sustained by males.”

http://parachutecanada.org/downloads/research/Canadian_Injury_Prevention_Resource-LR.pdf

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Injury Type

N=241

Figure 3

Again, in keeping with national and provincial trauma registries, Blunt type injuries are the majority

(n=152) of major trauma treated at the QEII. For minor trauma, the focus is on collecting Penetrating

trauma as indicated in by penetrating being the most frequent injury type (n=65). Blunt injury with a

minor score are collected as a result of collecting all Trauma Team Activations. It makes for an

interesting comparison when considering use of resources.

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Resource Utilization

Figure 4

Comparing the use of resources between Major and Minor trauma patients, it is obvious that minor

trauma use considerable resources despite the lack of severity. As shown in the chart above, major

trauma had 51 O.R. visits total minor trauma, a much smaller sample population (n=75), had 73 O.R.

visits. This registry does not collect minor trauma such as extremity and hip fractures, all of which score

only an average ISS of 9. Those other minor injuries treated at the QEII, and following the same

collection criteria as defined by the ATR, added up to 1524 as reported by DIMR.

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Mechanism of Injury

Figure 5

As in past years, injuries involving motorized vehicles (n=52) followed by falls (n=42) are the most

common causes of major injuries.

Of note, assaults account (n=17) and self-inflicted (n=12) minor injuries. This translates to minors

making up a total of 12% and major injuries only 9% of all injuries collected in the registry.

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ETOH Levels

Figure 6

ETOH levels were not collected consistently during 2015-16. Of those that were and tested positive, the

levels for both Major and Minor trauma patients were usually well beyond the legal limits as

demonstrated by the averages depicted in the chart.

“In 2015, police reported 72,039 impaired driving incidents, representing a rate of 201 incidents per

100,000 population. This is the lowest rate since data on impaired driving were first collected in 1986

(-65%) and 4% lower than in 2014.”

https://www150.statcan.gc.ca/n1/pub/85-002-x/2016001/article/14679-eng.htm

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Transport Related Injuries

Figure 7

There were a total of 100 Transport Related Injuries, combing both Major (n=100) and Minor (n=11)

scoring injuries. In this sample 78% (n=78) were male with an average age of 42 and 22% (n=22) were

female with an average age of 46.

32% (n=32) were “No (not tested) for ETOH”.

2% (n=2) were “Not Applicable (≤9 yrs old)”.

44% (n=44) were “No Alcohol (Confirmed by test)”.

20% (n=20) were “Yes (Beyond legal limit)”.

2% (n=2) were “Within legal limit”.

n=100

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Fall Related Injuries

Figure 8

Falls are the second highest mechanism of injury. During 2015-16 there were 42 falls resulting in major

injuries and 5 minor score injuries patients collected in the registry and treated at the QEII.

70% (n=31) were “No (not tested) for ETOH”.

9% (n=4) were “Not Applicable (≤9 yrs old)”.

15% (n=7) were “No Alcohol (Confirmed by test)”.

11% (n=5) were “Yes (Beyond legal limit)”.

0% (n=0) were “Within legal limit”.

n=47

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Interpersonal Violence

Of the top three mechanisms of injury, interpersonal violence is the third. Interpersonal Violence is a

combination of both assaults and incidents of self-inflicted injuries. Those injuries of undetermined

intent and as a result of legal intervention have not been included in this data.

Figure 9

Many of the injuries in this category are Penetrating type injuries and fall under the definition defined

by the ATR. As a result, there are more minor scoring injuries than major. The chart above depicts this

with 29 minor injuries, 21 major and the gender counts with average age ranges for each group.

52% (n=26) were “No (not tested) for ETOH”

2% (n=1) were “Not Applicable (≤9 yrs old)”.

8% (n=4) were “No Alcohol (Confirmed by test)”.

32% (n=16) were “Yes (Beyond legal limit)”

6% (n=3) were “Within legal limit”.

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Interpersonal Violence/Assault & Self Harm

Despite this population of trauma patients having a large percentage of minor trauma collected, and

because of the prevalence of penetrating injuries, there are considerable resources used as noted by the

number of operating room visits.

Figure 10

Also due to the nature of this category, it is responsible for 20% (n=3) of deaths due to trauma (n=15)

which will be depicted in the following chart.

“Suicide is a major cause of premature and preventable death. It is estimated, that in 2009 alone,

there were about 100,000 years of potential life lost to Canadians under the age of 75 as a result of

suicides.”

https://www150.statcan.gc.ca/n1/pub/82-624-x/2012001/article/11696-eng.htm

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Mortality

Figure 11

ages range from 5-89 with a mean of 50 yrs

14/15 are males

11/15 are Blunt type injuries

3/4 of the Penetrating injuries are assaults

7/15 died in the ED

“Alberta has the highest rates of interpersonal violence of any province in Canada. In the last five

years, nearly 75,000 Albertans have reported violence by a spouse or partner.”

https://www.ualberta.ca/public-health/news/2016/february/violence-is-a-public-health-problem

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Trauma Team Activation

Having a trauma team, comprised of specialized clinicians working together to care for trauma

patients, has been shown to improve their care and outcome. The QEII Trauma Program developed

a list of criteria to identify those patients who would benefit from a Trauma Team Activation. Since

2012 we have been tracking those cases in our registry in order to evaluate and provide in-site into

whether the most seriously injured trauma patients are receiving the standard of care.

Figure 12

Through the years of 2015/16, there were a total of 58 patients receiving Trauma Team Activations

(TTA/Yes) leaving 183 (TTA/No) who did not. TTA/No patients were comprised of 124 ISS ≥ 12 and 59 ISS

<12 while TTA/Yes patients had 42 ISS ≥ 12 and 16 ISS < 12. Combining all Injury severity scores and

looking at our activations by gender reveal 122 males vs 61 females in the TTA/No sample and 47 males

vs 11 females in the TTA/Yes sample.

N=241

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ED Arrival to O.R. TTA/Yes vs TTA/No

Discerning the efficacy of a TTA (Yes) vs TTA (No) is difficult. Plowing through medical notes is labour

intensive and often essential information such as adherence to process, communication and definitive

leadership are not clearly noted. One way to assess our quality of care is to look at timelines. For

example, does a TTA result in a patient getting to the operating table quicker than those who do not

have a TTA called?

Figure 13

Looking at average time of arrival in ED to the O.R. (excluding those patients that went to surgery >24

hours after arrival in ED) it appears as if the patients cared for with a Trauma Team Activation were taken

to the O.R. quicker, with an average time of 3:02, than those not receiving an activation (p=0.03).

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ED Arrival to CT

TTA/Yes vs TTA/No

Time to CT is another way to measure the impact of a Trauma Team Activation on patient care.

Figure 14

All patients entered in the registry and needing a CT to assess their injuries, excluding those who went

to CT prior to the emergency department, were used for this depiction (N=135). The evaluation showed

that those patients receiving an activation (TTA/Yes) were taken to CT in a significantly faster time than

those who did not (TTA/No).

ED Arrival to ED Discharge TTA/Yes vs TTA/No

“In a Level I trauma center, the outcomes of trauma patients with an ISS > 12 are statistically

significantly better if the trauma team is activated than if the patients are managed on an individual

service-by-service basis.”

https://insights.ovid.com/crossref?an=00005373-199611000-00020

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Time Spent in ED TTA vs No TTA

Figure 15

N=241

The amount of time most Canadians spend waiting in emergency departments to be admitted to

hospital is on the rise, whether they are medical or trauma patients. The patients captured by this

registry are all suffering significant and/or life threatening injuries and even this population is spending

longer in the emergency department than is optimal. However, for patients receiving a TTA, there is a

significant difference (p=0.008) in time spent in emergency before either being admitted or transferred

to a higher level of care.

“As a component of the trauma service, the trauma team has been independently shown to reduce

time in the resuscitation room, time to key investigations and to definitive care and reduce the rate

of missed injury, all of which contribute to mortality reduction.”

https://sjtrem.biomedcentral.com/articles/10.1186/1757-7241-18-66

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Time Spent in the ED

Time spent in the ED is of concern for all patients. The average time spent for all major traumas, regardless

of the poste ED destination or age, was 8 hours 21 minutes. Elderly patients suffering trauma are a

particularly vulnerable group. With an increase in age there is, generally, an increase of comorbid

conditions and a decrease in the body’s ability to recover.

Figure 16

This data, showing older patients waiting in ED significantly longer is concerning. If policy is followed,

there should be no notable difference in ED length of stay. So, why are all patients with major trauma

over the age of 60 spending more time in ED? Could it be injury specific?

Elderly (60 yrs +) LOS in the ED Elderly in the ED

Head Injury vs No Head Injury

“Early studies suggest that elderly patients may be less likely to be admitted to a trauma center after

an injury than are younger patients.”

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3121677/

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Average ED LOS ≥ 60 Years

Head Injury vs No Head Injury

There were 47 people, aged 60 years and over, with major trauma treated at the QEII through 2015 and

2016. Of those 47, 60% (n=28) were treated for head injury and 40% (n=19) had no head injury. The

average age of the Head Injury population is 72; No Head Injury population is 71.

Figure 17

It appears that older patients with a head injuries resulting in a major score are waiting much longer in

ED than their counterparts without a head injury. This is likely a matter of available resources. As the

QEII has no designated trauma ward, trauma patients are to be admitted onto the general surgery ward.

With beds at a premium, waiting for a medical bed for older head injured patients rather than admitting

them to a surgical bed may be the trend seen here.

“Traumatic brain injury (TBI) is a significant problem in older adults. In persons aged 65 and older, TBI

is responsible for more than 80,000 emergency department visits each year; three-quarters of these

visits result in hospitalization as a result of the injury. Adults aged 75 and older have the highest rates

of TBI-related hospitalization and death.”

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2367127/

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Elderly in the ED

Time to CT

Based on measurable timelines, there seems to be as quick a response to elderly as there are to the

younger patients. For example, time from ED arrival to first CT for major trauma patients no matter the

age is without significant difference.

Figure 18

The above chart shows the average time from arrival to E.D. to the CT table for ≥ 60 years of age and

<60, excluding those who had their first CT after admission to the ward (2 in each group). There is no

significant difference in the average time it takes to get trauma patients to CT regardless of age.

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Definitions Abbreviated Injury Scale or Abbreviated Injury Score (AIS): A numerical scale ranging from 1 (minor injury) to 6 (virtually un-survivable injury). Scores are subjective assessments of the severity of injury, assigned to specific anatomical diagnosis by trauma experts. Blunt Injury Type: Refers to the type of injury reflecting the cause of injury (i.e. a motor vehicle collision, a blow to the head). Blunt injury may include deep lacerations but does not include any injury in which a missile such as a knife or bullet enters the body. Collector: Specialized software from Digital Innovation, Inc. used by all participating trauma registries to collect pre-hospital demographics, nature and cause of injury, and follow up information on severely injured patients. Crude Injury Rate: A rate giving the total number of events occurring in an entire population over a period of time, without reference to any of the individuals or subgroups within the population. External Cause of Injury Codes (E-codes): Based on the International Classification of Diseases (ICD-9th revision). These codes allow for the classification and analysis of environmental events, circumstances, and conditions as to the cause of injury. All reports are based on the first recorded E-code, unless otherwise specified. ICD (International Classification of Diseases): The International Classification of Diseases is a World Health Organization (WHO) publication that classifies morbidity and mortality information for statistical purposes, and for the indexing of hospital records by disease and operations, for data storage and retrieval. ICD manuals may be found in hospital Health Record Departments or in public libraries. In-Hospital Death: An admitted patient who dies during their hospital stay following admission. This includes those patients who are dead on arrival (DOA) or who die in the Emergency Department (DIE). Injury Severity Scale or Injury Severity Score (ISS): The Injury Severity Score is an internationally recognized scoring system developed to assign a level of severity to an injury. As an extension of the Abbreviated Injury Scale (AIS) it is the sum of squares of the highest AIS score in each of the three most severely injured body regions. The ISS is scored 1 (minor) to 75 (major) with a higher score indicating increased severity and mortality. Length of Stay (LOS): Total number of hospital days as calculated from the date of admission through to the date of discharge or death inclusive. Major Trauma Patient: A person admitted to a trauma centre for treatment of an injury with an ISS ≥12. Median: A measure of central tendency of a set of observations; it is the 50th percentile (the point above and below which 50% of the data fall). Motor Vehicle: Any mechanical or electronically powered device, not operated on rails, which any person or property may be transported or drawn, operating on a public roadway or highway.

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Motor Vehicle Non-Traffic Incident: Any motor vehicle incident that occurs entirely in any place other than public highway or roadway. Motor Vehicle Traffic Incident: Any motor vehicle incident that occurs entirely on a public highway or roadway. Other Road Vehicle Incident: Any incident involving a transportation device, other than a motor vehicle, which can transport a person or property on a public roadway or highway (example: animal-drawn vehicles; animals carrying a person; pedal cycles, etc.) Pedal Cycle Incident: An incident that involves a pedal cycle, but not a motor vehicle. Penetrating Injury Type: Refers to an injury caused by a missile entering the body. Missiles include bullets, knives, and items such as pieces of sharp glass or metal. For the purpose of this report, the ATR definition is used for inclusion; “The primary mechanism of injury is penetrating. Primary mechanism of injury is defined as the type of mechanism leading to the patient’s most serious injury, defined by AIS severity. Penetrating is defined as an injury that occurs when an object pierces the skin and/or enters the body, creating an open wound (as per NTDB trauma type E-code criteria document http://www.in.gov/isdh/files/APPENDIXVIIIBAssigningTraumaType_NTDS.pdf). All penetrating trauma (irrespective of ISS) is to be captured. This includes any patient where: 1. The penetrating injury was the primary mechanism of injury a. ICD10 external cause of injury codes: W25, W260-9, W27, W28, W29, W30, W31, W32, W33, W3400-9, W44, W4500-9, W46, W53, W54-59 (only biting not striking against or other contact), X72-X7409, X78, X93-X9509, X99, Y22-Y2409, Y28, Y350, Y354, Y364. b. ICD10 external cause of injury codes typically classified as blunt, but where the most serious injury is obviously penetrating.” STARS: Shock Trauma Air Rescue Service T Test: A statistical hypothesis test in which the test statistic follows a Student's t-distribution under the null hypothesis. It can be used to determine if two sets of data are significantly different from each other. Trauma: Injury resulting from the transfer of energy further defined in accordance to the Canadian National Trauma Registry parameters as blunt or penetrating injuries and burns included in the International Classification of Diseases (ICD 9-CM), external cause of injury codes (E-codes) 800-998. Note: Poisonings, certain types of immersion, thermal, and exposure injuries are not included in this report as they fall outside the National Trauma Registry parameters for trauma. Transport Incident: Any incident (E800-E848) involving a device designed primarily for, or being used at the time primarily for, conveying persons or goods from one place to another. In classifying incidents which involve more than one kind of transport, the following order of precedence of transport incidents should be used: aircraft and spacecraft, watercraft, motor vehicle, railway, other road vehicles. Trauma Centre: Institution that is equipped and committed to providing specialized care to trauma patients. The QEII Regional Hospital is the Trauma Centre referred to in this report.

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List of Figures

Figure 1 Trauma Patient Volume by Age Group……………………………………………………………………………….…….13

Figure 2 Gender and Average Age……………………………………………………………………………………………….…………14

Figure 3 Injury Type………………………………………………………………………………………………………………………….……15

Figure 4 Resource Utilization…………………………………………………………………………………………………………………16

Figure 5 Mechanism of Injury…………………………………………………………………………………………………………………17

Figure 6 ETOH Results by Category of Collection……………………………………………………………………………………18

Figure 7 Transport Related Injuries………………………………………………………………………………………………………..19

Figure 8 Fall Related Injuries………………………………………………………………………………………………………………….20

Figure 9 Interpersonal Violence……………………………………………………………………………………………………………..21

Figure 10 Assault & Self Harm/Number of OR Visits……………………………………………………………………………...22

Figure 11 Mortality Numbers/Mechanism of Injury……………………………………………………………………………….23

Figure 12 Trauma Team Activations……………………………………………………………………………………………………….24

Figure 13 ED Arrival to OR TTA vs No TTA………………………………………………………………………………………………25

Figure 14 ED Arrival to CT TTA vs No TTA……………………………………………………………………………………………….26

Figure 15 Time Spent in ED TTA vs No TTA…………………………………………………………………………………………….27

Figure 16 Time Spent in ED < 60 Yrs old vs ≥ 60 Yrs Old…………………………………………………………………………28

Figure 17 Elderly in the ED Head Injury vs No Head Injury……………………………………………………………………..29

Figure 18 Elderly in the ED Time to CT……………………………………………………………………………………………………30

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List of Citations

http://parachutecanada.org/downloads/research/Canadian_Injury_Prevention_Resource-LR.pdf ........14

https://www150.statcan.gc.ca/n1/pub/85-002-x/2016001/article/14679-eng.htm ……………………………18

https://www150.statcan.gc.ca/n1/pub/82-624-x/2012001/article/11696-eng.htm ...............................22

https://www.ualberta.ca/public-health/news/2016/february/violence-is-a-public-health-problem........23

https://insights.ovid.com/crossref?an=00005373-199611000-00020 ……………………………………………..……26

https://sjtrem.biomedcentral.com/articles/10.1186/1757-7241-18-66 ...................................................27

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3121677/ ………………………………………………………….……..28

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2367127/.....................................................................29