Regional Trauma Service - Alberta Health Services. Program Report.....89 Calgary Firefighters Burn...

Regional Trauma Service Annual Report April 1, 2003 to March 31, 2004

Regional Trauma Services 2003/2004

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Calgary Health Region Annual Regional Trauma Services Report 2003/2004

Table of Contents

Organization Structure.....................................................................................................................................ii

Vision, Mission, Values, Roles ........................................................................................................................iii

Introduction ......................................................................................................................................................iv

Executive Summary.........................................................................................................................................2

Regional Trauma Services Activities ...............................................................................................................11

Alberta Children’s Hospital Paediatric Trauma Report....................................................................................21

Trauma Statistics & Outcome Data .................................................................................................................25

Trauma Statistics: Peter Lougheed Centre & Rockyview General Hospital...................................................44

Performance Indicators: Foothills Medical Centre..........................................................................................48

Performance Indicators: Alberta Children’s Hospital......................................................................................64

Pre-hospital Annual Report .............................................................................................................................74

Regional Department of Emergency Medicine Report ....................................................................................83

P.A.R.T.Y. Program Report .............................................................................................................................89

Calgary Firefighters Burn Treatment Centre Report .......................................................................................92

Tertiary Neurorehabilitation Program Reports.................................................................................................96

Traumatic Spinal Cord Injury Population ...............................................................................................96

Traumatic Brain Injury Population..........................................................................................................102

Calgary Injury Prevention and Control Services Report..................................................................................110

Appendices

Appendix A: Trauma Research Publications ........................................................................................150

Appendix B: Trauma Research Funding Summary ..............................................................................152


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ORGANIZATIONAL STRUCTURE (April 1st/2003-March 31st/2004) Regional Trauma Services personnel include: Southwest Portfolio: Foothills Medical Centre Site (FMC): Ms. Tracy Wasylak, Vice President Dr. Robert Abernethy, Executive Medical Director Ms. Nancy Guebert, Director, Inpatient Surgical Services & Trauma Services Dr. John Kortbeek, Regional Trauma Services Medical Director Ms. Dianne Dyer, Regional Trauma Services Manager Ms. Stacey Litvinchuk, Regional Adult Clinical Nurse Specialist Ms. Christi Findlay, Regional Trauma Services Data Analyst Ms. Maria Vivas, Regional Trauma Services Data Analyst Ms. Michelle Mercado, Regional Trauma Services Secretary Child & Women’s Health Portfolio: Alberta Children’s Hospital Site (ACH): Ms. Brenda Fischer, Vice President Dr. Brian Stewart, Executive Medical Director Ms. Corine Frick, Director Child & Adolescent Health Inpatient Programs for Children Dr. Robin Eccles, ACH Trauma Director Ms. Jeanette Pearce, Regional Paediatric Trauma Coordinator Ms. Maria Vivas, Regional Trauma Services Data Analyst Adult Trauma Committee Chairpersons: Dr. John Kortbeek: FMC Adult Trauma Care Committee Dr. Bruce Rothwell: Peter Lougheed Centre (PLC) Trauma Committee Dr. Nancy Zuzic: Rockyview General Hospital (RGH) Trauma Committee Paediatric Trauma Committee Chairperson: Dr. Robin Eccles, ACH Trauma Committee Acknowledgment to former personnel: Ms. Sandra Dowkes, Regional Trauma Services Secretary Ms. Michaile Lovatt, Regional Trauma Services Data Analyst Welcome to New Staff: Ms. Michelle Mercado, Regional Trauma Services Secretary (start date March 2004) Ms. Maria Vivas, Regional Trauma Services Data Analyst (start date March 2004) Ms. Sue Gudmundson, Director, Critical Care, ACH (start date July 2004) Ms. Sukhi Lally, Regional Trauma Services Data Analyst (start date November 2004) Special Acknowledgments: Ms. Sue Conroy, Director, Emergency, Urgent Care & Health Link for previous leadership as Program Director. Dr. John Kortbeek, Regional Trauma Services Medical Director for exemplary leadership and service to the trauma program, staff, patients and families (1992- November 2004) Ms. Michelle Mercado, Regional Trauma Services Secretary, for compilation and preparation of the 2003-2004 Annual Report


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REGIONAL TRAUMA SERVICES

http://www.crha-health.ab.ca/clin/rts/index.htm

Vision Excellence in trauma service delivery based on adequate financial and human resources, research-based quality improvement and education within a community that values integration, comprehensive rehabilitation and prevention.

Mission To provide and support a comprehensive, integrated and optimal system for the prevention, treatment and rehabilitation of injury focusing on the individual, family and community. Values • Respect: non-judgmental acknowledgment of the unique contributions, dignity and worth of individuals, being

able to disagree, value diversity. • Caring: sensitivity to and support for the well being of all. • Accountability: willing to give an account of/be responsible for ones autonomy (where autonomy =

actions/decisions taken within ones area/scope of responsibility). • Teamwork: a commitment to work together towards common goals through effective communication,

collaboration and tolerance for differences. • Growth: personal and organization commitment to lifelong learning; continuous improvement; mentoring and

sharing. • Quality/excellence: in care and practice/work; clear standards; continuous improvement. Roles • Provide care to those affected by trauma within Region 3, Southern Alberta, Southeast British Columbia, and

Southwestern Saskatchewan. • Develop/advance clinical services, education and research at Regional, Provincial and Federal levels. • Act as a clinical/education resource for rural & other urban communities. • Provide acute care services including emergency care, diagnostic imaging, operative & critical care, ongoing

surgical management & rehabilitation. • Link to, and support disaster planning services, prevention programs, pre-hospital care, rehabilitation & other

trauma programs. • Maintain the trauma registry database and report on patients with ISS > 12 (Foothills Medical Centre (FMC)

and Alberta Children’s Hospital (ACH). • Review/report on injury discharge data, emergency transfers (Rockyview General Hospital (RGH) and Peter

Lougheed Centre (PLC). • Assume a leadership role & active partnership in provincial and federal trauma services planning. • Facilitate quality monitoring & improvement activities including the review & development of clinical practice

guidelines, research initiatives, and the acquisition of applicable educational resources.


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INTRODUCTION The Calgary Health Region continues to experience growth in trauma academic activity and clinical service delivery. This year’s annual report reflects the scale and significance of these activities. The broad coalition of health providers required to provide comprehensive injury control and advance the knowledge of injury is immediately apparent when turning the pages. The maturity of the Calgary Health Region’s Trauma Service delivery model is reflected in the increasing number of publications and research dollars generated.

It has been a pleasure to work with partners across the expanding region who are committed to maintaining and improving the high standards achieved to date. The Calgary Health Region Trauma System continues to lead the country in reporting and benchmarking. Calgary’s strengths include comprehensive and coordinated pre-hospital ground and air ambulance services, a single coordinated regional Emergency Department, specialized surgical services including the dedicated Trauma Service and leadership in Spine, Orthopaedic, Reconstructive, Neurosurgical and Vascular Surgery services. The past several years have seen improved access to Tertiary Rehabilitation services in recruitment of additional physiatrists, an event which has been overdue and is welcomed by the entire community of trauma service personnel. The Calgary Health Region continues to be the only region in Canada which annually summarizes comprehensive performance indicators and publishes these in the public domain. Public reporting commits the Region to a high standard and hopefully will contribute to service delivery improvements across the country. System enhancement continues in coordination with the Alberta Centre for Injury Control & Research in developing and promoting the provincial trauma system proposal. This has been tentatively given a green light by Alberta Health; however, we still anxiously await attached dollars. The rapid growth of the Calgary and Southern Alberta population continues to challenge the current health care resources. Finally, however, an ambitious plan of expansion across the Region has been embarked upon which will create a significantly greater capacity in the Region by 2009.

The Alberta Children’s Hospital has engaged in an ambitious review of its Trauma Service delivery model with all departments participating in critical self-evaluation. Many constructive recommendations have been made and acted upon. The Trauma Association of Canada performed the first national re-accreditation in Calgary in the fall of 2004 as well as the first system-wide accreditation and review. The results of the accreditation were recently released and, not surprisingly, were positive. Several constructive recommendations for further development and improvement were forwarded and will be acted upon this year. It has been a pleasure to have served as the Director of Trauma Services for the Calgary Health Region and I looked forward to participating in working in Canada’s best trauma system in the years to come. John B. Kortbeek, MB, FACS, FRCSC Calgary Health Region

Regional Trauma Services Executive Summary Submitted by: Ms. Dianne Dyer, Manager Regional Trauma Services Calgary Health Region


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EXECUTIVE SUMMARY The Regional Trauma Services Program is dedicated to supporting and evaluating the provision of optimal trauma care to individuals and families affected by traumatic injury across southern Alberta, southeastern British Columbia and southwestern Saskatchewan. Services provided by the program support and enhance the ongoing development and advancement of clinical care, education and research pertaining to trauma patients and families across the continuum from pre-hospital care to discharge to the community. Various activities were undertaken by the team in collaboration with partners within the trauma system this past year to address identified needs and issues and ensure an efficient, effective integrated system of care. The annual report is a comprehensive summary of the Regional Trauma Services team activities, trauma statistics, performance measures, interrelated reports, and trauma research publication information. This year’s report also includes some data and trends for the past five years. The report and data is focused on April 1/2003-March 31st 2004. A unique feature this year is inclusion of a comprehensive pre-hospital annual report. 1. Regional Trauma Services Activities

1.1 Clinical An important component of the trauma service is to support, facilitate and evaluate clinical services. The goal is to improve and maintain the highest standard of trauma care through inter-disciplinary team collaboration, education and research. Enhancement of clinical practice through the development, implementation and evaluation of clinical practice guidelines, technology, and clinical collaborative projects supports achievement of this goal. Note: Current protocols and practice guidelines are available to clinical providers on the Regional Trauma Services internal website (established in February 2004) and in the revised Trauma Orientation Manuals for both adults and children. An external web site is also accessible with information on programs, services, related links and copies of annual reports. Clinical activities this year included revision of the adult spinal clearance protocol based on the ‘Canadian C-spine Rule’. Several new protocols, practice guidelines and role descriptions were developed for Unit 71, the FMC Trauma Unit. Trauma Team Activation criteria were revised to address concerns regarding clarity and comprehensiveness. Roles of all members of the Trauma Team were reviewed and clarified with role descriptions included in the orientation manuals. There was on-going team collaboration to address interventions for patients. One example was care of the patient with blunt aortic injury (i.e. endovascular stents). The equipment was purchased and the initial draft of the “Flow Chart for Aortic Arch Injuries” was designed for implementation in the Fall 2004. There was on-going review of clinical patient care and issues on a daily basis. Mortality and Morbidity (M & M) rounds were held every Friday throughout the year and residents, nurses and trauma surgeons discussed patient complications, issues and deaths. Specific site and system issues were identified and addressed through Trauma Services in collaboration with appropriate departments at both FMC and ACH sites.

1.2 Education

Promoting educational opportunities for clinical providers, managers and support staff is essential and integral to an effective trauma program. Educational activities this year included the presentation of Trauma Rounds on a weekly and/or monthly basis. The adult monthly trauma rounds were presented on Telehealth at all acute care sites and rural sites (upon request). Members of the Regional Trauma Services team participated and/or presented at the Trauma Association of Canada (TAC) Annual Scientific Meeting held in Mont Tremblant, Quebec on March 31st - April 3rd 2004. Team members were fully funded to attend using external sources and minimal operations funding. Physicians and nursing students were provided practicum and clinical rotation opportunities. A presentation of the Provincial Trauma Proposal was made to the Standing Policy Committee of the Alberta Provincial Government in July 2003. The Minister of Health was in attendance and the proposal was well received. Funding has not yet been finalized. A presentation on the Trauma System in Calgary was given to the Hadassah Women’s Annual luncheon. The event was a fundraiser to raise money to build a Trauma Centre in Israel. One member of the Trauma Services team attended the “Chain of Survival” conference offered by Calgary Emergency Medical Services and the Calgary Fire Department in October 2003. A primary focus of the conference was Disaster Planning. Members of the team participated in the new Trauma Nurses Journal


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Club and the Critical Care Nurses Journal Club. The Trauma Nurses Journal Club started in Spring 2003 and has been very successful; meeting every two months.

1.3 Quality Improvement

The measurement and evaluation of various components of the adult and paediatric trauma system is a primary focus of the work of Trauma Services. Throughout the year referrals were made to Trauma Services by trauma care providers with specific concerns for follow-up. The ACH and FMC trauma and audit committees conducted quarterly and ad hoc reviews of Trauma Registry statistics, performance indicators and audit filters. The PLC and RGH site trauma committees conducted quarterly and ad hoc case reviews. Standards and benchmarks applied to other trauma organisations were reviewed. Morbidity & Mortality (M & M) rounds were facilitated and cards were completed identifying issues, deaths, and complications. Performance indicators, audit filters and clinical practice guidelines were reviewed and updated as appropriate.

1.4 Research

Trauma research and evidence based practice is an essential focus of Trauma Services and an effective trauma system. Research activities this year included the establishment of a fund at the University of Calgary called the Trauma Research Fund. The fund provides “seed money” to support the initiation of research by students and trauma care providers. The Adult Trauma Care Committee at FMC determined eligibility for funding. A Trauma System Researcher from Australia was invited to Calgary and met with various groups to review the Canadian trauma system and practices. She presented an excellent overview of the Australian Trauma System to conclude her visit. The Trauma/Critical Care Outcomes Research group continued to meet. This group was comprised of a multidisciplinary team of research experts and new researchers. The focus was to provide support, guidance and a forum to discuss research questions, projects and potential funding options. $1,835,185 total funding was received to support trauma related research projects this year.

A comprehensive list of research publications, projects, funding sources and related information are included in the appendices section of this annual report.

1.5 Administration

Administrative support is essential to the co-ordination and support for trauma services activities. This year the administrative support activities included continuing work to further develop and implement the integrated Provincial Trauma Proposal. Budget proposals were submitted and presentations were made to Alberta Health & Wellness. Links and support for the Trauma Association of Canada were maintained. A capital funding proposal for the implementation of Trauma Registry at the PLC and RGH sites was approved. The trauma services team worked with Capital Health Region trauma services team to prepare a summary of data and information on the Trauma Services Programs in Alberta for Province Wide Services (PWS). This document was published in the 2003 PWS Annual Report. A proposal for funding to support the Regional Trauma Accreditation process was submitted and approved. The accreditation review has been scheduled for October 2004. Various proposals for internal and external funds were submitted throughout the year to seek support for team and system activities. There was active participation in the initial discussions and planning sessions focused on the development of a new ‘state of the art’ Simulator Education Centre. A process to explore the possible move of the 15-17 year old population from Foothills Medical Centre to the new Alberta Children’s Hospital in 2006 was facilitated by Trauma Services. Final decisions have not been made to date.

1.6 Data Management

As part of TAC guidelines, an accredited trauma centre must have a trauma registry. Both FMC and ACH have a stand-alone trauma registry. To qualify for the trauma registry a patient must have an ISS > 12 and be admitted to the trauma centre or die in the emergency department of the trauma centre. ISS is an anatomical scoring tool that provides an overall score for patients with single system or multiple system injuries. To ensure all appropriate patients are included into the trauma registry, all injury admissions, discharges and emergency department resuscitations are reviewed at FMC and ACH. This fiscal year,


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3214 FMC patient records and 634 ACH patient records were reviewed to determine eligibility for the trauma registry. Once registry eligibility was determined, data was abstracted from the patient record and entered into the trauma registry. This was a manual process although efforts are underway to try and feed some of the information electronically into the trauma registry from, for example, TDS 9000 or the Regional Emergency Department Information System (REDIS). Data was retrieved and analyzed for internal quality improvement initiatives with Regional Trauma Services (FMC and ACH Trauma Committees) and with departments involved in the care of the trauma patient. Following the appropriate approvals, the registry was also used as a source of data for research, resource utilization, education and injury prevention initiatives, and outcome studies. FMC and ACH data was submitted to the Alberta Trauma Registry (ATR) central site based at the University of Alberta Hospital (U of A) in Edmonton. Data was submitted from the central site onto the National Trauma Registry of Canada. PLC and RGH trauma patients were not included into the trauma registry at this time, however, issues and concerns were identified in three ways: (1) by chart review based on injury discharge codes and (2) by review of trauma follow-up forms generated by nursing/medical staff and (3) referrals. Trauma Registry software has been purchased to collect data for patients meeting the inclusion criteria who are cared for at the PLC and RGH. It should be operational in April 2005. Source: Data Management section prepared by Christi Findlay, Data Analyst.

2. Trauma Statistics & Outcome Indicators (FMC & ACH)

Major Trauma patient numbers and other related data included patients with an Injury Severity Score (ISS > 12) and who were admitted to hospital or died in the FMC or ACH emergency departments. ISS is an anatomical scoring tool that provides an overall score for patients with single system or multiple injuries. The higher the ISS score, the more severe the patient’s injuries. Based on these inclusion criteria, these totals represent 24.3% of injury discharges at FMC and 13.9% of injury discharges at ACH. In the fiscal year 2003/2004, the FMC total was 860 patients. The ACH total was 97 patients. Both FMC and ACH experienced an increase in annual trauma case totals (11.4% and 4.3% respectively). Adding the PLC and RGH major trauma cases to the total, the number of major trauma patients for this year was 1009 patients. The total number of overall traumatic injury discharges for 2002-2004 was 7770 patients. This was a decrease from the previous year (101 patients) however; the number of patients that qualified as major trauma for this year increased by 100 patients. Adult male patients consistently out number females ≥ 2:1. In 2002/2003, the ratio was 2.7:1. In 2003/2004 the ratio was 3:1. At ACH the male to female ratio for 2003/2004 was 2.2:1, an increase from 1.6:1 in 2002/2003. Data collected at the FMC continues to demonstrate the national trend; the majority of the trauma population (58%) was between the ages of 15-44, with the greatest representation in the 15-24 age range. The age group 65 and over was 18.1% of the overall population. There was an increase in this age group of 28 patients or 22% over the previous year. At the ACH, the data indicates an increase in the percentage of trauma patients > 10 years of age, 54.6% this year compared to 49.5% in 2002/2003. As in previous years, the mechanism of injury (MOI) or cause of injury was reported by four broad categories: transportation, falls, violence and other. These were in keeping with the focus of the Calgary Health Region’s injury control initiatives. "Transportation" continues to be cited as the “number one” MOI in data collected at FMC and ACH, accounting for 50% and 44.3% of the registry cases respectively (FMC 52.9%, ACH 46.2% 2002/2003). "Violent" causes of injury represent 12.4% (107) of FMC, and 7.2% (7) of ACH trauma registry totals (FMC 10.4%, ACH 9% 2002/2003). The adult male to female ratio was 7:1 in 2003/2004, a huge increase from 2:1 in 2002/2003. There was one noticeable difference in the Fall MOI category related to females age > 65 years of age. The number of females that sustained a fall in 2002-2003 in this age group was 23 patients. The number for 2003-2004 was 46 patients or exactly double the previous year. ‘Type of injury’ categories are used to broadly describe the type of force that results in injury. In both the adult and paediatric population, the majority of injuries were the result of blunt forces. When comparing 2003/2004 to 2002/2003 at the FMC, there was an 11.2% increase in blunt trauma, a 16.7% increase in penetrating


Executive Summary 5

trauma, a 44.4% increase in burn related trauma and a 75% increase in other. At the ACH, blunt trauma remained stable, penetrating trauma increased from 0 (2002/2003) to 1 (2003/2004). 73.3% of patients were transported to the FMC Trauma Centre by ground ambulance, a 20.7% (108 patients) increase from 2002/2003. 64.9% of patients transported to the ACH were transported by ground ambulance, an 18.9% (10 patients) increase from 2002/2003. Air transports for FMC decreased by 1%, while air transports to ACH decreased by 21.4%. The majority of trauma patients at the FMC site were admitted under the services of the general surgeon, followed by the intensivist. At the ACH, the ICU service was responsible for the majority of trauma admissions, followed by paediatrics (includes hospital-based paediatricians).

Trauma patients may undergo a variety of specialized surgical procedures. There was a decrease in the orthopaedic procedures performed at FMC this year from 424 (2002-2003) to 364 in 2003/2004. Orthopaedics continues however; to perform the highest number of surgical procedures at FMC and ACH. In 2003/2004, physicians performed 933 surgical procedures on major trauma patients at the FMC. The procedures were done during 581 visits to the operating rooms, requiring 1500 operating room hours. While this was an 11.4% decrease from the number of surgical procedures performed in 2002/2003 (1053), there was little difference in the number of operating room visits (583) or operating room hours (1499). In 2003/2004 at the ACH, 55 surgical procedures were performed on major trauma patients during 37 operating room visits, totalling 80 operating room hours. While there was a 9.8% reduction in surgical procedures performed (2002/2003: 61), in 2003/2004 there were more operating room visits (2002/2003 - 33) requiring more operating hours (2002/2003 - 65). In 2003/2004, 29.5% (34.4% 2002/2003) of major trauma admissions were admitted to the FMC ICU. FMC Trauma ICU admissions comprised 23.4% of the total overall ICU admissions of 1087 for the fiscal year. At ACH, 54.6% of major trauma admissions were admitted to the ICU (38.7% 2002/2003). Access to ICU beds at both sites presents many challenges. The median overall hospital LOS has demonstrated little to no change over the past 5 years. This included the acute phase of the hospital stay at FMC, not the rehabilitation phase, which can range from days to months. Outcomes were identified through Trauma Registry using age, major mechanism of injury (MOI), ISS scores, mortality rates and discharge location. In 2003/2004, there was a decrease in the percentage of older adult trauma patients who died from injuries sustained (18.7%), compared to 2002/2003 (19.6%). Of the younger adult age groups (< 65), 7.9% died (10.5% in 2002/2003). At ACH, the 1-4 age group experienced the highest mortality (25%). In 2002/2003, 16.7% died in this age group. At the FMC, falls claimed the highest % of lives (11.1%) followed by violence (10.3%), then other (10.1%) and lastly transportation at 9.5%. At the ACH, mortality was highest in the violence category at 28.6%. Other followed this at 10%, transportation at 7%. No deaths occurred in the falls category. The mortality rate at FMC (10.1%) decreased slightly when compared with 2002/2003 (11.9%). The mortality rate at ACH (7.2%) decreased since 2002/2003 as well (9.6%). The majority of all of the major trauma patients were discharged home. The number of traumatic injury discharges for patients in the > 18 year age group was consistently high across the Region ranging from 234 patients in November to 359 patients in July. The ability to accurately predict peaks in adult trauma patient numbers and therefore staffing resources was not very reliable and presented many challenges at FMC. The patients < 18 years demonstrated a more consistent pattern with increases in the summer months and December. In 1992, the inclusion criteria for the Trauma Registry was an ISS > 16. In 1993, this was revised to an ISS > 12. At FMC, there has been a 34.5% increase in the number of patients with an ISS > 16 over the last 5 years (1999-2000: 530 patients). This is a similar pattern at the ACH where there was a 33.9% increase in 2003/2004 when compared to 1999/2000. This rise in major trauma cases has resulted in increased pressures on acute care and community resources, with demands for improvements in performance, technology and efficiency measures.


Executive Summary 6

3. Trauma Statistics & Outcome Indicators (PLC & RGH)

The RGH and PLC Trauma Committees reviewed all of the major trauma admissions (ISS ≥ 12). All of the admissions were assessed as appropriate admissions to the sites. In some cases, specific site issues or challenges were identified and referred to the specific departments for follow-up. Patient may arrive at these sites by ground ambulance, walk-in or private vehicle. The patients were identified for review using the three processes outlined in the PLC/RGH trauma statistics section of this report. At PLC, in 2003/2004, 22 major trauma patients (ISS > 12) were admitted and discharged from the site. At RGH, in 2003/2004, 30 major trauma patients (ISS > 12) were admitted and discharged from the site. The major trauma patients at RGH tend to be older than the patients at PLC.

4. Performance Indicators

As part of the Regional Trauma Services quality improvement process, several indicators throughout the continuum of care are monitored on a regular basis as a measure of performance. The following is a summary of these indicators at Foothills Medical Centre and the Alberta Children’s Hospital for patients who meet the inclusion criteria for the Alberta Trauma Registry (patients with an ISS > 12 and who are admitted to the hospital or die in the ED at the FMC).

4.1 Foothills Medical Centre (FMC)

Each performance indicator number was based on the specific determinant of the indicator within the total of 860. The FMC Quality Improvement Committee and Trauma Services reviewed the data and charts, and addressed identified issues. There were some differences in the transport data for this year. One example was an increase in the number of major trauma patients (ISS > 12) transferred from the PLC and RGH sites to FMC site. The increase at PLC was from 24 (2002/2003) to 28 patients. There was a larger increase at RGH; from 19 patients (2002/2003) to 33 patients. In the Alberta Centre for Injury Control and Research (ACICR) Provincial Proposal (June, 2001) five centres were identified as proposed District Trauma Centres: Lethbridge Regional Hospital, Medicine Hat Regional Hospital, Red Deer Regional Hospital, Queen Elizabeth II Hospital, Grande Prairie, and Northern Lights Regional Hospital, Fort McMurray. In the proposal, each identified District Centre strives to become a Trauma Association of Canada accredited trauma centre, which includes the establishment of a trauma team, a trauma registry and adequate educational and equipment resources. 84 patients were transferred to FMC from one of the proposed District Centres (63 patients, 2002/2003). The number of out of province transfers to FMC decreased from 48 (2002/2003) to 40 this year. Of the 40 out of province transfers, 33 or 82.5% of the patients were transferred from British Columbia. Use of a mechanical airway as an intervention for patients with a Glasgow Coma Scale (GCS) score < 8 at the scene and in Emergency Departments (ED) is the standard of care. In the pre-hospital phase 47.1 % of patients with a GCS < 8 (a measure of neurological status) had a mechanical airway. This was a decrease from the last two years (47.3% in 2002/2003, 52.2% in 2001/2002). In the ED, compliance with this indicator continues to improve from 68% (2001/2002), 81.8% (2002/2003), to 85% in 2003/2004. The Trauma Team Leader (TTL) response time should be within 20 minutes of arrival of the patient to the trauma centre. This year this criterion was met 96.2% of the time (92.3% in 2002/2003). Some revisions were made to the trauma team activation criteria in summer 2003 to try to ensure clarity and appropriate response. There were instances where the trauma team was activated and the patient injury severity score was <12. In 2003/2004 there were 429 documented trauma team activations in total, 235 patients were classified as major trauma (ISS ≥ 12). In this fiscal year, of the 75 cases in which the criteria were met but the team was not activated, 32 or 42.7% were single system head injured patients. Of the Category #1 laparotomy patients (hemorrhagic shock), 69.7% went to the OR within one hour, compared with 50% last year. The median time to the OR for this category of patient was 47 minutes compared to 89.5 minutes in 2002/2003.


Executive Summary 7

There was improvement in the compliance with the orthopaedic indicators. The time for joint dislocation to reduction should be one hour. Compliance improved from 31.3% (2002/2003) to 51.4% for 2003/2004. The time for femur fracture to operative management should be 24 hours. Compliance improved from 80.6% (2002/2003) to 96.2% this year. The compliance with timing for long bone open fracture operative repair improved from 82.5% (2002/2003) to 90% this year. The time to craniotomy for a patient with a subdural or epidural should be within 4 hours of arrival to the trauma centre. Compliance improved from 84% (2002/2003) to 86.4%. There was a 76% increase in the number of patients requiring craniotomies and qualifying for this indicator. The length of stay for major trauma patients in the ED has continued to increase. The ED length of stay was > 4 hours 62.5% of the time for 2003/2004 (50.1% in 2001/2002, 56.4% in 2002/2003). The average length of stay was 7.3 hours; median 5.2 hours. The percentage of patients with a missed injury/delayed diagnosis decreased from 4.3% in 2002/2003 to 1.9% in 2003/2004. Of the missed injuries 62.5% were extremity injuries. The immobile patient should receive documented thrombolytic therapy within 24 hours of admission to a trauma centre. There was improved compliance in the last year from 76.8% of the patients in 2002/2003 to 80.8% in 2003/2004. The numbers may not reflect true compliance, as it is often a challenge for the data analysts to locate ‘documented prophylaxis’ in the chart. The improvement may relate to the introduction of pneumatic stockings for all patients on the trauma unit unless otherwise ordered. The percentage of patients who died within 24 hours, out of the total number of patients that died, increased from 53.3% 2001/2002, 55.4% in 2002/2003 to 60.9% this year. The mortality rate overall decreased from 12% in 2002/2003 to 10.1% in 2003/2004. The number of patients that died with a probability of survival > 20% was 3.1% this past year compared to 3% in 2002/2003. For 1995 - 2004, there was 1.99 more survivors per 100 than would have been expected from the major trauma outcome study (Trauma Score Injury Severity Score (TRISS) Methodology)

4.2 Alberta Children’s Hospital

Each performance indicator number was based on the specific determinant of the indicator within the total of 97. The ACH Audit Committee and Trauma Services reviewed the data and charts, and addressed identified issues. If the ACH Audit Committee identified cases where there were questions, the committee generated letters to follow up on those cases. ACH Transport team data indicated an increase by one transport in the past year. 40 patients (85.1%) of the transfers did not utilize the service compared to 30 or 83.3% for 2002/2003. The majority of children transported to ACH arrived by ground ambulance. All cases not transported by the team were reviewed, to determine whether the patient would have benefited from the service. Cases of concern were followed up with the sending centre. Use of a mechanical airway as an intervention for patients with a GCS score < 8 at the scene and in Emergency Departments (ED) is the standard of care. In the pre-hospital phase 25% of the patients with a GCS < 8 (a measure of neurological status) had a mechanical airway. In many of the cases there were unsuccessful attempts to secure the airway with a mechanical airway at the scene. This was a decrease in compliance from the last two years (42.1% in 2002/2003, 50% in 2001/2002). This information has been provided to the ACH Audit Committee for review and follow-up as appropriate. In the emergency department (ED), compliance with this indicator improved from 50% (2002/2003) to 100% in 2003/2004. The time spent at sending hospitals (outside of the Calgary Health Region) prior to patient transfer was < 2 hours in 34.6% of the cases. This new indicator combined the secondary and the primary hospitals into the sending hospital. In 2002/2003, 48% of the primary hospitals and 100% of the secondary hospitals respectively met the standard. Injury time to trauma centre improved over 2002/2003 however, 30.8% of the patients (20/65 patients) arrived at the trauma centre > 4 hours from time of known injury event.


Executive Summary 8

There was an increase in the ACH ED LOS (standard of < 4 hours) compared to last year. 56.4% of the patients met the standard this year compared to 60.5% in 2002/2003 and 63.4% in 2001/2002.

At ACH, activation of the trauma team is through ED at the discretion of the ED physician. All major trauma cases are reviewed through the ACH audit process. The Trauma Team was activated 39 times in the 2003/2004 year with 21 of the activations between the months of June and September. The time to operative management of femur fractures should be 24 hours; 88.9% of the patients met the standard, compared to 83.3% in 2002/2003. All patients with open bone fractures (4 patients) and facial fractures (3 patients) met the standards set for those indicators. 100% of the patients requiring a craniotomy for a subdural or epidural hematoma (4 patients) met the standard of operative management within 4 hours.

There were no unplanned returns to the OR, one unplanned ICU admission and no unplanned ICU readmissions. The percentage of patients with a missed injury/delayed diagnosis decreased from 3.4% in 2002/2003 to 2.1% in 2003/2004. There were no missed c-spine injuries Of the 7 patients that died, the number of patients who died within 24 hours of admission was equal to the number in 2002/2003 (5 patients). The percentage mortality overall decreased from 9.7% in 2002/2003 to 7.2% in 2003/2004. The number of patients that died with a probability of survival > 20% was 1.5% this past year compared to 0% in 2002/2003. For 1995 - 2004, there were 2.99 more survivors per 100 than would have been expected from the major trauma outcome study (Trauma Score Injury Severity Score (TRISS) Methodology).

5. Reports

A number of reports were submitted this year from various trauma system partners for inclusion in the annual report. The reports include:

• The Pre-hospital Annual Report • The Regional Department of Emergency Medicine report • The P.A.R.T.Y. Program report • The Calgary Firefighters Burn Treatment Centre report • Two Tertiary Neurorehabilitation Program reports • The Calgary Injury Prevention and Control Services report

These reports are an important addition to the annual report and demonstrate and support the complexity and comprehensiveness of the integrated Calgary Health Region trauma system.

6. Current Projects/Future Directions

Regional Trauma Services will continue to provide leadership in trauma care and quality improvement locally, provincially, nationally and internationally. To ensure that our system is working efficiently and effectively for patients and their families, we have submitted a request for Regional funding support and received approval for a request to the Trauma Association of Canada for renewal of our trauma accreditation status in 2004. In the past, the process was accreditation of the FMC and ACH sites only, however, this time the accreditation will focus as well on the trauma system. We will be the first in Canada to undergo this comprehensive overall system review process. We welcome feedback and are very willing to learn and address any deficiencies that may be identified

These are just a few of the projects planned for the next year:

• Performance Indicators and Audit Filer review and reporting (within a 3-6 month target) • Mortality & Morbidity rounds and database management


Executive Summary 9

• Research and seeking external funding opportunities • Internal/External website management and further development • Regional and Public Communication Projects • Province Wide Services Trauma Mapping Model development and evaluation • Telehealth Education and Clinical Linkages • Simulator Project Development • Electronic Health Record Support • Provincial Trauma Proposal implementation • Successful Trauma System accreditation by the Trauma Association of Canada in October 2004 • Continued work to explore the feasibility of moving the 15-17 year old population from the FMC site to the

new ACH site in 2006 • Introduction of Trauma Registry to the data collection and case review processes at the PLC and RGH

sites

Trauma Services will continue to promote and support system performance through data management and quality improvement projects, clinical leadership and initiatives based on current trauma research, clinical evidence and measurement of performance. For more information contact our web site at:

Regional Trauma Services

http://www.crha-health.ab.ca/clin/rts/index.htm


Regional Trauma Services Activities Submitted by: Ms. Dianne Dyer, Manager Regional Trauma Services Calgary Health Region


Activities 11

REGIONAL TRAUMA SERVICES ACTIVITIES Regional Trauma Service continues to provide support for trauma care in the following areas: 1. Clinical

An important component of the trauma service is to support, facilitate and evaluate clinical services. The goal is to improve and maintain the highest standard of trauma care through inter-disciplinary team collaboration, education and research. Enhancement of clinical practice through the development, implementation and evaluation of clinical practice guidelines, technology, and collaborative projects supports achievement of this goal. Note: Current protocols and practice guidelines are available to clinical providers on the Regional Trauma Services internal website (established in February 2004) and in the revised Trauma Orientation manuals. Copies of current Trauma Orientation Manuals for adults/paediatrics and updates are posted on the website. Clinical activities this year included: • Completion of the revisions of the adult and paediatric Trauma Orientation Manuals. • Internal website development • Further revision of the adult spinal clearance protocol based on the ‘Canadian C-spine Rule’. The revised

protocol was circulated to all Trauma Committees across the Region. Feedback was incorporated. • Continuing work to address the challenges and care of the acute brain injured patient within the acute

care and rehabilitation settings. The team consisted of representatives from neurosurgery, Regional Trauma Services, nursing, physiotherapy, occupational therapy, medicine and Quality Improvement & Health Information (QIHI). A protocol called “Management of Post Traumatic Agitation Following Brain Injury” was developed and approved. Other steps were also implemented including staff training and further applications of the Ranchos Los Amigos scale (i.e. assessment, interventions and evaluation).

• Revision and circulation of the adult and paediatric protocols for treatment of hypothermia. • Further development of protocols/practice guidelines/role descriptions for Unit 71, the FMC Trauma Unit. • Further revision of the criteria for Trauma Team Activation in order to add clarity and comprehensiveness. • Clarification and further defining of the roles of all members of the Trauma Team. This information was

included in the revised Trauma Orientation Manuals (e.g. Trauma Team Leader, Residents, Emergency Physicians, Social Work etc.)

• Confirmation of the pre-hospital criteria (PHI) with the pre-hospital providers and the literature. • Development of a protocol for care of patients with delirium tremens (DTs) based on literature and clinical

practices. The new protocol was approved, piloted and implemented on Unit 71 and circulated to other sites for application when appropriate.

• Gathering information on the three adult sites regarding physician practices regarding ordering Computerized Tomography (CT) for minor head injury. Practice variations and issues were identified across sites. The Canadian CT Head (Ottawa Rule) was determined to be the ‘gold standard’ for practice by a committee of experts and implemented in December 2003 in the adult Emergency Departments.

• On-going team collaboration to address interventions for the patient with blunt aortic injury (i.e. endovascular stents). The team consisted of representatives from Vascular Services, Surgical Services, Trauma Services and Diagnostic Imaging. Funding to purchase appropriate diagnostic imaging equipment for the FMC site was acquired through the FMC Development Council. The equipment was purchased and the initial draft of the “Flow Chart for Aortic Arch Injuries” was designed. Implementation is planned for Fall 2004.

• Introduction and implementation of checklists for Neurological Determination of Death for Adults, children > one year, infants < 1 year, and term newborns > 36 weeks gestation. (Source: Severe Brain Injury to Neurological Determination of Death: A Canadian Forum)

• On-going review of clinical patient care and issues on a daily basis and through Mortality and Morbidity (M & M) rounds held every Friday throughout the year. System issues are identified and addressed through Trauma Services in collaboration with appropriate departments.


Activities 12

2. Education

Educational activities included:

• Presentation of Trauma Rounds on a weekly and/or monthly basis. The adult monthly trauma rounds were presented on Telehealth at all acute care sites and rural sites (upon request).

• Participation and/or presentation by members of the Regional Trauma Services team at the Trauma Association of Canada (TAC) Annual Scientific Meeting held in Mont Tremblant, Quebec in March/April 2004. Team members were fully funded to attend using external sources and minimal operations funding.

• Preceptorship and support for four Faculty of Nursing Undergraduate Students. The focus of the practicums was quality improvement and research. The students assisted with literature reviews, data collection and analysis for various projects.

• Leadership and clinical guidance for clinical clerks, residents and Fellows during their trauma surgery rotations. The students were from Calgary, other provinces and other countries.

• Presentation of the Provincial Trauma Proposal to the Standing Policy Committee of the Alberta Provincial Government in July 2003. The Minister of Health was in attendance and the proposal was well received. Funding has not yet been finalized.

• Participation in a one-day Leadership Conference on June 9th/2003. • Participation in the Emergency Operations Centre Training sessions offered by Disaster Services. • Attendance at the one-day QI Forum on September 18th/2003 focusing on patient safety. • Attendance at a 6-week series of classes on Research Methods offered by the Health Sciences Centre. • Presentation on the ‘Trauma System in Calgary’ at the Hadassah Women’s Annual luncheon. The event

was a fundraiser to raise money to build a Trauma Centre in Israel. • Attendance at the “Chain of Survival” conference offered by Calgary Emergency Medical Services and the

Calgary Fire Department in October 2003. A primary focus of the conference was Disaster Planning. • Participation in the Trauma Nurses Journal Club and the Critical Care Nurses Journal Club. The Trauma

Journal Club started in Spring 2003 and has been very successful with a meeting every two months. The interest and attendance increased every meeting with a growing interest in research/research processes. The Trauma Nurses Journal Club is sponsored by Aventis.

• Assisted the Calgary Domestic Violence Committee with the development of a Trauma Grand Rounds on Domestic Violence and the Emergency Screening program. The Grand Rounds were held in November 2003 and were very well received.

• Presented information on the Trauma System to the OR Nurses Education Day held at the Rockyview General Hospital.

ATLS® • Student Provider Courses: 2003 - Apr 10-12; May 22-24; Jun 19-21; Oct 23-25

2004 - Feb 26 - 28; Mar 18 - 20 • Student Provider Courses: 2003 - Nov 22-23

Dr. John Kortbeek is the Region Chief, ATLS® Region XI. There are, including Dr. Kortbeek, eight Course Directors: Drs. Rob Mulloy, Bruce Rothwell, Jim Nixon and Jeff Way and three new trauma surgeons (Drs. Ian Anderson, Morad Hameed and Andy Kirkpatrick); recruited for this role in 2003). There are 48 instructors in good standing: Anesthesia - 3, Emergency Department - 9, General Surgery - 17, Intensive Care Unit - 4, Orthopaedic Surgery - 8, Plastic Surgery - 1, Family Medicine - 1. Sandra Dowkes has been the ATLS® Coordinator in Calgary since 1998 and is currently working with a new coordinator - Nancy Biegler (Patient Care Manager, Unit 71) with whom she will partner on future courses. Canadian ATLS® coordinators held an inaugural meeting, under the auspices of the Trauma Association of Canada's annual spring meeting in Mt. Tremblant, Quebec, on April 1, 2004.


Activities 13

Trauma Grand Rounds, FMC Auditorium, 0730-0830

2003 April 25 Amputee Management and the New Amputee Clinic Dr. Dan McGowan May 30 The P.A.R.T.Y. Program Lynda Vowell, RN BN September 26 Testifying in Court Dr. Pauline Alakija October 24 Gang Violence in Calgary Staff Sgt. Ken Marchant November 28 Domestic Violence Screening in the Emergency Departments: “WHY

SHOULD YOU CARE?” Linda McCracken, RN

Debra Carnat, MSW RSW Cathie Belenky, RN Jan Dietsche, RN

2004 January 23 Fall Prevention Mr. Frank Macdonald RN NP GNC (C) February 27 Trauma in War and Poverty

Stories from the Sudan and the Himalayas Dr. Geoff Ibbotson

FMC Trauma Friday Noon Conference Rounds, C818, 1200-1300

2003 Presenter Topic April 4 Resident’s Pick 11, 18 CANCELLED 25 Dr. Randy Moore Blunt Aortic Injury/Peripheral Vascular Trauma May 9 Michelle Goecke (Resident) Journal Club: Trauma Outcomes in the Elderly 16 Dr. John Hurlbert Spinal Fractures 20 Dr, Tony Mclean Colorectal Trauma 30 Residents Journal Club June 6 Dr. Walter Hader Management of Head Injury 13, 20, 27 CANCELLED July 4 CANCELLED Stampede Parade 11 Scott Gmora (Resident) Bedrest in Pts Managed Non-operatively for Blunt Splenic

Trauma 18 Darby Cassidy (Resident) Journal Club: Blood Transfusion, Independent of Shock…. 25 Nurses Trauma Presentation: The Effects of Nurse Staffing… August 1 Danny Goel (Resident) Risk factors and time course of sepsis and organ

dysfunction… 8 Committee Trauma Research Group – Projects Review 15 Residents M&Ms 22 CANCELLED 29 Dr. Mike Betzner Air Transport Issues September 5 Committee Trauma Research Group – Projects Review 12 Kris Lundine (Resident) Radiographic cervical spine evaluation in the alert

asymptomatic..


Activities 14

19 Wendy Reardon BSW RSW Discharge Planning 26 Heather Cox (Resident) FAST Ultrasound October 3 Committee Trauma Research Group – Projects Review 10 Kate Hyatt RN BN MRNCA Collaborative Regional Trauma Management Model 17 CANCELLED 24 Resident Presentation or M&M 31 Michelle Goecke Electrical Burns November 7 Dean Malish (Resident) Prospective validation of computed tomographic

screening… 14 Linda McCracken RN The Forensic "ABCD's" of Trauma Care 21 Journal Club 28 Resident Presentation December 5 Committee Trauma Research Group – Projects Review 12 Dr. Ian Anderson Hypothermia 19 Journal Club

2004 January 19 Dr. Kevin Laupland Nosocomial Infections 16 Dr. Morad Hameed Trauma Research Group 23 Dr. Anas Al-Kassem Shock and Management 30 Danny Goel (Resident) Trauma Case in ICU February 6 CANCELLED 13 Dr. Burton-Macleod

(Resident) Trauma Case Presentation

20 Southern Alberta Brain Injury Society (SABIS)

Acute Brain Injury Follow Up and Discharge Planning

27 Heather Bray (SABIS) Head Injury Rehab March 5 Dr. Ian Anderson, Trauma

Clerks, Trauma Fellows Trauma Discussions: Trauma Wound Management

12 Dr. Anas Al-Kassem Emergency Thoracotomies 19 Dr. Morad Hameed Trauma Research Group 26 Dr. Andrew Kirkpatrick Trauma Association of Canada (TAC) Medical Presentation

Teaching Opportunities • University of Calgary weekly Trauma Resident Rounds – Trauma

Services Calgary Continuous

• University of Calgary weekly Trauma Conference Noon Rounds – Trauma Services

Calgary Continuous

• University of Calgary Undergraduate Trauma Seminars – Trauma Services

Calgary Continuous

• University of Calgary Critical Care City-wide Rounds, CPC – FMC Calgary Continuous • University of Calgary Academic Half-days Calgary Continuous • Critical Care Resident Presentations Calgary Continuous • Critical Care Nursing Symposium Calgary December • TAC Annual Conference & Scientific Meeting Mont

Tremblant, Québec

March 31st - April 3rd 2004

Rounds sponsored by


Activities 15

3. Quality Improvement

The measurement and evaluation of various components of the adult and paediatric trauma system is a primary focus of the work of Regional Trauma Services. Quality improvement activities throughout the year included:

• Referrals to the Trauma Services by trauma care providers with specific concerns for follow-up. • Quarterly and ad hoc reviews of Trauma Registry statistics, performance indicators and audit filters by

ACH and FMC trauma and audit committees. This applies to the major trauma population only. • Quarterly and ad hoc case reviews at PLC and RGH site trauma committee meetings. Issues and cases

were identified through various sources including: referrals, discharge lists, chart reviews and follow-up forms.

• Review of standards and benchmarks applied to other trauma organisations. • Morbidity & Mortality (M&M) rounds and completion of cards identifying complications, issues, deaths. • Daily case reviews on the nursing units and timely reporting and follow-up. • Reviewing, critiquing and creating reports and documents from a trauma service perspective. Documents

this year included the Alberta Child & Teen Major Trauma report and the Province Wide Services submissions.

• On-going review of all deaths and all laparotomies through chart audit processes. • Review and revision of performance indicators, audit filters and clinical practice guidelines annually and

as appropriate. 4. Research

Trauma research and evidence based practice is an essential focus of Regional Trauma Services. Research activities this year included:

• A fund was established at the University of Calgary called the Trauma Research Fund. The fund provides

“seed money” to support the initiation of research by students and trauma care providers. Eligibility for funding is determined by the Adult Trauma Care Committee at FMC.

• A Trauma Nurses Journal Club was established and attendance continues to grow. Funding support is provided by Aventis.

• Facilitation of the visit by a Trauma System Researcher from Australia who met with various groups to review the Canadian trauma system and practices. She presented an excellent overview of the Australian Trauma System to conclude her visit.

• Members of the Regional Trauma Services team continue to participate in the Regional Nursing Research Committee and site research committees.

• Dr. Morad Hameed established the Trauma/Critical Care Outcomes Research group last year. This group was comprised of a multidisciplinary team of research experts and new researchers. The focus was to provide support, guidance and a forum to discuss research questions, projects and potential funding options. Currently there are more than 10 new research projects in progress or submitted for publication, in addition to the list of projects and publications in this report.

$1,835,185 total funding was received to support trauma related research projects.

A comprehensive list of research publications, projects, funding sources and related information are included in the appendices section of this annual report. 5. Administration

Administrative support is essential to the co-ordination and support for trauma services activities. This year the administrative support activities included:

• Promotion of the integrated Provincial Trauma Proposal. The goal is an integrated provincial system for

trauma, which aims to get the injured trauma patient to the right location, the right provider and the right


Activities 16

services in a timely manner. Regional Trauma Services worked closely with Capital Health Region Trauma Services to provide Provincial Trauma Proposal presentations to trauma care providers and administration at proposed District Centres. These centres included Lethbridge Regional Hospital, Red Deer Regional Hospital, Medicine Hat Regional Hospital, Queen Elizabeth II Hospital in Grand Prairie and the Northern Lights Regional Hospital in Fort McMurray. Actively involved in budget proposals and presentations to Alberta Health & Wellness.

• Maintenance of ongoing links with TAC and the Trauma Coordinators of Canada. Ms. Jeanette Pearce, Regional Paediatric Trauma Coordinator, sat on the National Executive.

• Acquisition of funding through Aventis to support weekly and monthly Trauma Rounds and the Trauma Nurses Journal Club.

• Acquisition of funding from the Trauma Association of Canada (TAC) to support the TAC secretary role within Regional Trauma Services.

• Acquisition of funding from Advanced Trauma Life Support (ATLS®) to support the ATLS® coordinator role within Regional Trauma Services.

• Submission of quarterly trauma services reports to the Calgary Health Region quarterly Board Report. • Acquisition of Regional Capital funding to implement Trauma Registry at the PLC and RGH sites. • Submission of annual reports to Province Wide Services (PWS). Worked with Capital Health Region to

prepare a summary of data and information on the Trauma Services Programs in Alberta. This document was published in the 2003 PWS Annual Report and very well received.

• Participation in the FMC and Regional Disaster planning meetings to ensure input from Trauma Services and access to updates on new developments.

• Acquisition of external funding to send four team members to the TAC conference held in Mont Tremblant, Quebec in March/April 2004.

• Monitoring and management of the Trauma Research Fund and smaller research funds under the University of Calgary Financial Services Department. To date this process has worked very well for the various researchers and our program.

• Continued to meet with the Regional PWS representative to ensure input into PWS funding allocations. • Seeking and receiving approval for funding to support the Regional Trauma Accreditation process

scheduled for October 2004. • Participation in a meeting to review and evaluate the role of the Alberta Centre for Injury Control &

Research held on November 30th/03 in Calgary. • Participation in the Calgary Traffic Safety meetings with Calgary City Police Services. The meetings

planned two campaigns to prevent pedestrian/car incidents in the future. Both campaigns were well received by the public.

• Participation in the initial discussions on the Simulator Education Centre. Trauma Services will be a partner in this Centre.

• Facilitation of the process to explore the possible move of the 15-17 year old trauma population from FMC to the new ACH site in 2006. Data analysis will occur in May 2004.

Committee Representation: Calgary Health Region: • ACH, PLC and RGH Trauma Committees • FMC Adult Trauma Care Committee (ATCC) • FMC Trauma Resuscitation Committee • The University of Calgary Surgical Undergraduate Education Committee (SUGEC) • The University of Calgary, Critical Care Fellowship Steering Committee • FMC Trauma Quality Improvement Committee (TQI) • ACH Audit Committee • Adult Critical Care Nursing (ACCN) Advisory Committee • Emergency/Trauma Portfolio Meetings • Site Managers meetings (all sites) • Regional Disaster Planning Committee • FMC Disaster and Emergency Response Planning Committee • Calgary Injury Prevention Coalition Communications Committee • Traffic Safety Task Force (Calgary & Region)


Activities 17

• Canadian Intensive Care Foundation (CICF), Golf for Life Organizing Committee • Intensive Care Unit (ICU) Executive Committee • ICU Quality Council Committee • ICU Research Committee • ICU Continuous Quality Improvement Committee (CQI) • Aboriginal Health Injury Prevention Committee • Regional Nursing Research Committee • Registered Nurse & Clinical Nurse Specialist Job Description review committees • Spinal Cord Injury Pathway committee Provincial: • Alberta Ambulance Medical Review Committee • American College of Surgeons, Alberta Chapter • Alberta Ambulance Advisory and Appeal Board • Alberta Association of Registered Nurses • Alberta Public Health Association National: • Trauma Association of Canada Executive Committee • Trauma Association of Canada Abstract Review Panel • Royal College of Physicians & Surgeons of Canada Test Committee for General Surgery • Trauma Coordinators of Canada Executive Committee • Canadian Nurses' Association International: • American College of Surgeons, Alberta Chapter • American College of Surgeons Committee on Trauma & ATLS® Subcommittee • Editorial Review Panel, Journal of Trauma & Injury

6. Human Resource Activities

Ms. Stacey Litvinchuk was hired into a new role as the Adult Clinical Nurse Specialist in April 2003. The Trauma Coordinator position was reclassified into a Clinical Nurse Specialist role for Adult Trauma. Ms. Michelle Mercado was hired as the new Regional Trauma Services secretary. She replaced Ms. Sandra Dowkes, who resigned her position in January 2004 to pursue new opportunities at Mount Royal College. Ms. Michaile Lovatt resigned her position as Trauma Data Analyst to seek new opportunities. Ms. Maria Vivas, Data Analyst, replaced her on March 22nd 2004.

Regional Trauma Services assumed temporary management of the PARTY program during manager transitions in FMC Emergency. Dianne Dyer assisted with the revision of the PARTY Coordinator position and was successful in the application to move the role to Management Exempt in October 2003. A job description was developed and approvals were received for a .5 FTE Assistant PARTY Program Coordinator position. The new employee started in February 2004. The PARTY program management responsibility was transferred back to FMC Emergency in January 2004.

7. Data Management

As part of TAC guidelines, an accredited trauma centre must have a trauma registry. Both FMC and ACH have a stand alone trauma registry. The software used is called Collector. The application was developed by an American company and is supported by Digital Innovation based out of Maryland, USA. This application is used by over 200 hospitals worldwide including hospitals in Canada, the U.S., Australia, New Zealand and Sweden. It is a complete data management tool and report writing package. It has been in use at the FMC and the ACH since April 1995. To qualify for the trauma registry a patient must have an ISS > 12 and be admitted to the trauma centre or die in the emergency department of the trauma centre. ISS is an anatomical scoring tool that provides an overall score for patients with single system or multiple system injuries. Each injury is assigned an Abbreviated Injury


Activities 18

Scale (AIS) score and is allocated to one of six body regions (head, including cervical spine; face; chest, including thoracic spine; abdomen, including lumbar spine; extremities, including pelvis; and external). Only the highest AIS score in each body region is used when calculating the ISS. The three most severely injured body regions have their score squared and added together to produce the ISS score. The higher the ISS, the more severe the patient’s injuries are. To ensure all appropriate patients are included into the trauma registry, all injury admissions, discharges and emergency department resuscitations are reviewed at FMC and ACH. This fiscal year, 3214 FMC patient records and 682 ACH patient records were reviewed to determine eligibility for the trauma registry. Once registry eligibility was determined, data was abstracted from the patient record and entered into the trauma registry. This was a manual process although efforts are underway to try and feed some of the information electronically into the trauma registry from, for example, TDS 9000, Quality System (QS) and Regional Emergency Department Information System (REDIS). Data collected included patient demographics, mechanism of injury information, pre-hospital information, sending hospital information, trauma centre emergency department information, trauma centre inpatient information including operative information, injury diagnosis information, outcome information and specific audit filters and performance indicators. The Health Information Act (HIA), section 27(1)(g), outlines clearly the parameters whereby we are authorized to collect this data. Effort is made to gather as much information as possible. In some cases, follow-up is necessary with pre-hospital providers and sending hospitals. Data was retrieved and analyzed for internal quality improvement initiatives with Regional Trauma Services (FMC and ACH Trauma Committees) and with departments involved in the care of the trauma patient. Following the appropriate approval process, the registry was also used as a source of data for research, resource utilization, education and injury prevention initiatives, and outcome studies. Collector supports unique projects by providing the ability to customize the trauma registry and to write queries and reports. FMC and ACH data was submitted to the Alberta Trauma Registry (ATR) central site based at the University of Alberta Hospital (U of A) in Edmonton. The central site also collected data from the U of A Hospital and the Royal Alexandra Hospital in Edmonton. Data was submitted from the central site onto the National Trauma Registry of Canada. Regional Trauma Services works closely with colleagues in Edmonton to develop and maintain a consistent data dictionary ensuring a comprehensive and comparative data set. PLC and RGH trauma patients were not included into the trauma registry at this time, however, issues and concerns were identified in three ways: (1) by chart review based on injury discharge codes and (2) by review of trauma follow-up forms generated by nursing/medical staff and (3) referrals. Trauma Registry software has been purchased to collect data for patients meeting the inclusion criteria who are cared for at the PLC and RGH. It should be operational in April 2005.

8. Current Projects/Future Directions

Regional Trauma Services will continue to provide leadership in trauma care and quality improvement locally, provincially, nationally and internationally. To ensure that our system is working efficiently and effectively for patients and their families, we have submitted a request for Regional funding support and received approval for a request to the Trauma Association of Canada for renewal of our trauma accreditation status in 2004. In the past, the process was accreditation of the FMC and ACH sites only, however, this time the accreditation will focus as well on the trauma system. We will be the first in Canada to undergo this comprehensive overall system review process. We welcome feedback and are very willing to learn and address any deficiencies that may be identified

These are just a few of the projects planned for the next year: • Performance Indicators and Audit Filer review and reporting (within a 3-6 month target) • Mortality & Morbidity rounds and database management • Research Funding and external funding opportunities • Internal/External website management and development • Regional and Public Communication Projects • Province Wide Services Trauma Mapping Model development and evaluation


Activities 19

• Telehealth Education and Clinical Linkages • Simulator Project Development • Electronic Health Record Support • Provincial Trauma Proposal implementation • Successful Trauma System accreditation by the Trauma Association of Canada in October 2004 • Working closely with the Alberta Children’s Hospital teams to continue to explore the feasibility of the

potential move of the 15-17 year old major trauma population from the FMC site to the new Alberta Children’s Hospital opening in 2006.

• Introduction of Trauma Registry to the data collection and case review process at the PLC and RGH sites. Regional Trauma Services will continue to promote the integrated Provincial Trauma System proposal and support system performance through data management and quality improvement projects and initiatives based on current trauma research, clinical evidence and measurement of performance.

Alberta Children’s Hospital Paediatric Trauma Report Submitted by: Dr. Robin Eccles, Paediatric Trauma Director Ms. Jeanette Pearce, Regional Paediatric Trauma Coordinator Calgary Health Region


Pediatric Trauma Report 21

PAEDIATRIC TRAUMA REPORT In the fiscal year 2003-2004, Dr. Robin Eccles continued in her position as Chair of the Trauma Committee and Ms. Jeanette Pearce continued in her position as Regional Paediatric Trauma Coordinator. Ms. Michaile Lovatt left her position as the Data Analyst for the Paediatric Trauma Program in late January 2004. A new data analyst, Maria Vivas, was hired to commence work on March 22nd 2004. One of Maria’s primary roles was to review and enter the backlog of Alberta Trauma Registry cases that had accumulated during the vacancy period in preparation for future Audit Committee meetings. Trauma Service Activities The Paediatric Trauma Program had many planning initiatives this year. Ongoing planning occurred to assess the feasibility of accepting age 15-17 year old major trauma patients at the new ACH site. Within each division - from the surgical subspecialties to Diagnostic Imaging, Calgary Laboratory Services, Emergency Medicine and Rehabilitative Medicine - meetings were held to determine what would be required to care for this population. At the Division of Paediatric Surgical Retreat in November 2003 the major topic presented by Dr. Robin Eccles and Dr. John Kortbeek was “Trauma in the New Alberta Children’s Hospital”. Another major planning initiatives began in the fiscal year was the Trauma Association of Canada Accreditation. The Accreditation is planned for October 2004 but planning began at the Alberta Children’s Hospital in January 2004 to review the guidelines and prepare the documents required. The new updated Trauma Manual for ACH was finished and released to the hospital in December 2003 and January 2004. Committee Representation • Alberta Children’s Hospital Trauma Committee • Trauma Committee Community Member • Trauma Audit Committee • Child Health Advisory Council • Regional Injury Executive Committee • Calgary Injury Prevention Coalition • Alberta Children’s Hospital Surgical Executive Committee • Intermediate Care Advisory Committee • Intensive Care Advisory Committee

Education The Paediatric Transport Course began in the fiscal year to train Registered Nurses and Respiratory Technologists for transport of critically ill and paediatric trauma patients as a physician-less transport team.



REGIONAL PAEDIATRIC TRAUMA COORDINATOR The position of Regional Paediatric Coordinator continued as a 0.53 FTE part time position held by Jeanette Pearce RN BN. Major initiatives this year focused around preparation for TAC trauma system accreditation. The five components of Coordinator responsibilities included; clinical, data management, quality improvement, administration and education. The Regional Paediatric Trauma Coordinator represented paediatric trauma care within the Calgary Health Region, for Southern Alberta and nationally with active participation through the TCC – Trauma Coordinators of Canada. ACTIVITIES Clinical

• Ongoing clinical tracking of major trauma patients/families; mainly those with injury severity scores of ISS > 12

- explored issues/concerns related to pre-hospital, transport or intra-hospital management - provided support for staff when issues were raised including the development of spinal

precautions definitions, reporting on incidence of and injury prevention for falls, facilitation of coordination amongst multiple disciplines with difficult cases at ACH, and consultation for paediatric trauma management questions from RGH, PLC and FMC sites

- referred patients/family members to appropriate departments when gaps were identified (i.e. psychology, brain injury rehabilitation team, social work, parent/community resources)

- facilitated age appropriate admissions/transfers to ACH from FMC - provided telephone follow-up for a family following spinal cord injury, ensuring access to

resources via child welfare and maintenance of follow-up appointments - led critical incident stress diffusing as Critical Incident Stress Management (CISM) peer in

February 2004 • Maintained casual status as Staff RN, ACH ED

Data Management

• Worked with data analyst support to gather major trauma statistics for Alberta Trauma Registry data base - participated in prospective screening through admission report review and retrospective

screening through discharge summary review - facilitated responses to data requests from local Calgary Health Region contacts (i.e. nurses,

physicians, students), provincially (i.e. referring hospitals in Southern Alberta) and nationally (i.e. fellow trauma centre care providers)

- assisted the data analyst to determine Trauma Registry eligibility for complex cases Quality Improvement

• Assumed responsibility for data analysis reporting, audit review and documentation following regular ACH Trauma Audit Committee meetings held in April 2003, June 2003 (2 meetings), November 2003 and January 2004. Followed up on issues identified as appropriate.

• Facilitated amendments to ACH ED trauma record to aid in ease of use and to support improved trauma documentation

• Monitored paediatric trauma admissions and management at PLC and RGH through Regional discharge summary review and chart audits. Reported at Regional TQI meetings when issues were identified

• Reviewed cases, by request from within and outside Region 3, and followed-up by involving appropriate staff to gather details of the cases. Feedback was provided to staff requesting the review. Reported system-related issues were referred to the ACH Trauma Director or to the ACH Trauma Committee

• Coordinated formal QI feedback from a family who had experienced major trauma and were treated at ACH. Reported recommendations at ACH Trauma Committee and facilitated changes, when possible, to improve communication between social work departments at ACH and FMC (Feb. /2004)

• Completed revisions to ACH Trauma Manual, with input from ACH Trauma Committee members and disseminated manual Region-wide (Dec. /2003)



• Surveyed ACH ED nursing staff regarding team functioning during Trauma Team Activations. Responses indicated moderate to high levels of team cooperation and occasional confusion with trauma team leadership roles

Administration

• Collected and analyzed data related to the 15-17 yr old trauma population and the potential impact on trauma patient management at the new ACH site (projected to open in 2006). Facilitated information sharing with ACH OR educator staff and in-patient cluster management staff to assist with planning

• Initiated a data search to investigate current rehabilitation bed utilization at ACH in order to predict rehabilitation bed needs should the 15-17 yr old population be predominantly managed at the new ACH site. Shared the data summary with ACH Trauma Committee members and the Hospitalist staff

• Participated as a key contact at ACH for TAC trauma system accreditation preparation beginning in January 2004. Collated “Pre-Questionnaire” data collected from multidisciplinary departments at ACH and disseminated updates through Department Heads. Coordinated preparation efforts for the ACH ED department upon their request

• Continued work toward Child Health nursing policy and procedure development for compression stocking use and Aspen collar application for the paediatric patient

Education

• Participated at the “Severe Brain Injury to Neurological Determination of Death” Forum in Vancouver in April 2003. Presented the recommendations from the forum with the ACH ED Medical Director at ACH Trauma Rounds in January 2004

• Facilitated links with the Aspen collar representative to assist preparations for spinal precautions ‘trauma booth’ preparation for Paediatric Nursing Update 2004

• Presented trauma cases highlighting the challenges of spinal immobilization and recognition and management of splenic injury at the ACH ED annual mandatory education days held April 5th, 14th and 17th 2003

• Developed trauma related questions for ACH ED annual nursing exam • Presented paediatric trauma annual statistics and performance indicators at ACH Trauma Rounds in June

2003 • Presented a paediatric data summary at Regional Trauma Services Annual Report presentation in

October 2003 • Investigated adding disaster orientation for nursing staff at ACH; added questions to annual exam in ED

and had Fire Safety Instructor include questions in ad hoc “spot checks” with staff • Provided ACH ICU and ED new RN trauma orientations, May, June 2003 and March 2004 • Developed and provided ACH Resident staff trauma orientation, June 2003 • Provided a paediatric trauma session for third year nursing students in October 2003 • Taught at the Emergency Nursing Paediatric Course (ENPC) at the ACH in September 2003 and PLC in

November 2003 • Assisted with planning and moderating at the Calgary Injury Prevention Coalition (CIPC) Traffic Safety

event in January 2004 • Presented the ACH QI indicators and the review process to the TCC group at the TAC conference in

March 2004 • Personal professional development: certified as an instructor for the Paediatric Canadian Triage Acuity

Scoring (CTAS) course, maintained certification as an ACLS, TNCC, and PALS provider and as an ENPC instructor



Contacts

• ACH Resource Nurse for rehabilitation following brain injury: partnered to develop objectives for a brain injury care plan for ACH

• Kidsafe Connection, Injury Prevention Coordinator: shared information and initiated follow-up on child safety restraint use in major trauma cases

• Represent western Canadian provinces as the communication officer for the TCC Executive. Role involved regular executive tele-conference meetings and providing updates or soliciting feedback from fellow TCC. Participated on the planning committee for TAC annual conference for 2005.

• Represented paediatrics as a Trauma Coordinator on the TAC Paediatric Committee, beginning in June 2003

• Shared paediatric trauma management practices from the Calgary Health Region perspective, when appropriate, with trauma-focused personnel across Canada.

ACH Trauma Rounds

2003

April 24 H.O.P.E. Program Ms. Anne-Marie Martin

May 22 C.H.I.R.P.P.: New (Scooter) and Old (Shopping Cart) Injuries Dr. C. Nijssen-Jordan

June 26 Trauma Registry Stats Presentation Ms. Jeanette Pearce

October 23 GLD - Graduated Drivers Licensing Reducing Injury Risk for Teen Drivers Ms. Carol Beringer-Brown

November 27 Adolescent Trauma in the New ACH - Does it mean Sex, Drugs and Alcohol? Dr. Robin Eccles

2004 January 22 “Determination of Brain Death”

National Recommendations Dr. Francois Belanger and Ms. Jeanette Pearce February 26 “What’s New in Splenic Trauma?” Dr. Osama Bawazir March 25 “Implementation of Multi-Disciplinary Guidelines on Identification,

Investigation and Management of Shaken Baby Syndrome” Ms. Linda Anderson, Coordinator for Child Abuse, ACH

Trauma Statistics & Outcome Data ISS ≥ 12 April 1, 2003 - March 31, 2004 & 5 year trends

Foothills Medical Centre

Alberta Children’s Hospital Submitted by: Ms. Christi Findlay, Data Analyst Ms. Maria Vivas, Data Analyst Regional Trauma Services Calgary Health Region


Stats & Outcome - FMC &ACH 25

MONTHLY TRAUMA TOTALS Monthly trauma totals include patients with an Injury Severity Score (ISS) > 12 and who are admitted to hospital or die in the emergency departments at the Foothills Medical Centre (FMC) and Alberta Children’s Hospital (ACH). ISS is an anatomical scoring tool that provides an overall score for patients with single system or multiple injuries. The ISS captured in the Alberta Trauma Registry ranges between 12 and 75. The higher the ISS, the more serious the injury. Based on these inclusion criteria, these totals represent 24.3% of injury discharges at FMC and 13.9% of injury discharges at ACH. In the fiscal year 2003/2004, the FMC total was 860 patients. The ACH total was 97 patients. Both FMC and ACH experienced an increase in annual trauma case totals (11.4% and 4.3% respectively) August accounted for the largest monthly trauma case total at both FMC and ACH, with the rise in numbers commencing in April at FMC site. As expected, summer months accounted for high numbers of major trauma cases at both sites. The number of patients injured in December 2003 was lower at FMC than the number in 2002 (i.e. 74). It was higher at ACH in 2003 (i.e. 6 in 2002). Trauma numbers can be very unpredictable.

FMC - 2003/2004

71 7382

98 104

85

60 6556 61 54 51

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

# of

Pat

ient

s

ACH - 2003/2004

9 8

11 11

16

810

3

7 6 53


# of

Pat

ient

s

YEARLY TRAUMA TOTALS The FMC five year trend demonstrates rising major trauma case numbers over the first three years, with an increase (16.5%) in 2001-2002, a slight decrease in 2002/2003 (2.5%) and another increase in 2003/2004 (11.4%). The ACH five-year trend, shows a gradual decrease and increase in the first three years, with an increase (25.3%) in 2001-2002, a decrease (6.1%) in 2002/2003 and an increase in 2003/2004 (4.3%).

FMC - 5 year trend

626 680792 772

860

99/00 00/01 01/02 02/03 03/04

# of

Pat

ient

s

ACH - 5 year trend

84 79

99 93 97

99/00 00/01 01/02 02/03 03/04

# of

Pat

ient

s



Calgary Health Region (CHR) Trauma Cases Projection

PROJECTED GROWTH IN ADULT MAJOR TRAUMA CASES FOR SOUTHERN ALBERTA

The Quality Improvement and Health Information (QIHI) Health Assessment Unit made the following five-year predictions for FMC major trauma case totals. The process and indicators for these projections included: • For the five fiscal years (1995-1996 through 2001-2002), the average annual adult major trauma case rate

(based on adult major trauma patients treated at FMC) for Southern Alberta (Health Regions 1 through 5) has been 55 (± 7*) cases per 100,000 adults.

*7 is the standard deviation around the average

• Given a population growth rate of 3% and an average annual major trauma case rate of 55 per 100,000

(lower 48/upper 62), the chart below depicts the forecasted number of adult major trauma cases that would be admitted and treated at the FMC during the next five years.

• Expected utilization rates for Southern Alberta (Health Regions 1-5) was derived using five-year averages

between 1995-1996 and 1999-2000 for defined age-gender cohorts. Maximum utilization rates were derived using the average +1 standard deviation for each cohort and minimum utilization rates were derived using the average -1 standard deviation.

The number of actual adult major trauma cases (ISS >12) in 2003-2004 (i.e. 860 cases) exceeded the total predicted maximum number by 155 cases or 22%. In 2002-2003, the actual number of adult major trauma cases (i.e. 772) exceeded the prediction by 87 cases or 12%. Calgary’s population is growing rapidly and is the primary source of major trauma cases in Southern Alberta. The June 2003 Calgary census total was 922,315 with a prediction of 1 million people by 2007. The Calgary Health Region, as of April 1, 2003, encompasses 35.1% of the Alberta population, with a growing demand for resources.

Data Source: Health Assessment Unit Legend: = Maximum numbers using the average +1 standard deviation = Mean between the maximum and minimum numbers = Minimum numbers using the average –1 standard deviation

CHR: Projected Number of Adult (aged 18 and older) Major Trauma Cases to 2004/05 Fiscal Year

562546530515500584564572510

385

573 590 607 626 644

726705685645 665

0100200300400500600700800

95/96 96/97 97/98 98/99 99/00 00/01 01/02 02/03 03/04 04/05

num

ber o

f adu

lt m

ajor

trau

ma

case

s



MALE/FEMALE As noted in previous trauma reports, males continue to out number females in the total adult and paediatric trauma population. Adult males consistently out number females ≥ 2:1. In 2002/2003, the ratio was 2.7:1. In 2003/2004 the ratio is 3:1. At ACH the male to female ratio for 2003/2004 is 2.2:1, an increase from 1.6:1 in 2002/2003.

FMC - 5 year trend

477 495589 559

148 184 201 208 214

646

99/00 00/01 01/02 02/03 03/04

# of

Pat

ient

s

Male Female

ACH - 5 year trend

54 59 57 5767

3019

41 36 30

99/00 00/01 01/02 02/03 03/04

# of

Pat

ient

s

Male Female

AGE DISTRIBUTION Data collected at the FMC continues to demonstrate the national trend; the majority of the trauma population (58%) is between the ages of 15-44, with the greatest representation in the 15-24 age range. In this fiscal year, 41.5% of the trauma population was 45 or older, compared with 40.8% in 2002/2003. The age group 65 and over years of age was 18.1% of the overall population. There was an increase in this age group of 28 patients or 22% over the previous year. At the ACH, the data indicates an increase in the percentage of trauma patients > 10 years of age, 54.6% this year compared to 49.5% in 2002/2003. A gradual increase in the number of patient in this age group has been noted over the past 3 years.

FMC - 2003/2004

4

221

137 140 146

55 62 69

24

0-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 >84

# of

Pat

ient

s

ACH - 2003/2004

7

2017

36

17

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

# of

Pat

ient

s

Excludes 2 patients with unknown age.



MECHANISM OF INJURY (MOI) As in previous years, MOI is reported by four broad categories: transportation, falls, violence and other. These are in keeping with the focus of the Calgary Health Region’s injury control initiatives. "Transportation" continues to be cited as the “number one” MOI in data collected at FMC and ACH, accounting for 50% and 44.3% of the registry cases respectively (FMC 52.9%, ACH 46.2% 2002/2003). "Falls" resulting in major injury accounted for 28.4% (244) of patients at FMC (26.9% 2002/2003). At ACH, falls constituted 27.8% (27) of cases (30% 2002/2003). "Violent" causes of injury represent 12.4% (107) of FMC, and 7.2% (7) of ACH trauma registry totals (FMC 10.4%, ACH 9% 2002/2003). Limitations of the ISS scoring system in evaluating penetrating injuries that involve single system or single organ injuries may lead to under representation of violence. “Other” MOI contributed to 9.2% (79) of the total at FMC (9.6% 2002/2003). At ACH 20.6% (20) patients were admitted for “other MOI” (13.9% 2002/2003). “Other” is defined as unspecified, or not within the three categories defined above. Please see Mechanism of Injury – Other, page 32 for further clarification.

FMC - 2003/2004

430

244

107 79

Transportation Falls Violence Other

# of

Pat

ient

s

ACH - 2003/2004

43

27

7

20


# of

Pat

ient

s

The following four pages show a further breakdown of each category: • transportation • falls • violence • other



MECHANISM OF INJURY – TRANSPORTATION Motor vehicle collisions (MVC) comprise 37% (318) of all major traumas at FMC. This is in keeping with 38% last year. In the transportation category, MVC’s represent 74% (72.4% 2002/2003). At the ACH, MVC’s account for 18.6% of all major paediatric trauma cases at ACH (compared to 25.8% 2002/2003). MVC’s consist of 41.9% of the transportation category which is down from 55.8% 2002/2003.

FMC 2003/2004

318

5028 26

3 3 2

MVC Ped Off Road Pedal Rail Air Water

# of

Pat

ient

s

ACH 2003/2004

18

5 5

14

1 0

MVC Ped Off Road Pedal Water Air

# of

Pat

ient

s

FMC - 5 year transportation total trend

302356

423 406 430

99/00 00/01 01/02 02/03 03/04

# of

Pat

ient

s

ACH - 5 year transportation total trend

3136

43 43 43

99/00 00/01 01/02 02/03 03/04

# of

Pat

ient

s

Transportation MOIs are a leading cause of injury and death among young adults. In 2002/2003 data indicates that the number of 15-24 year old patients injured in transportation related incidents was 89. This year the number has risen to 98 for this same age group. Over 5 years (1996-2001) in Alberta, there were 208 teenaged drivers seriously injured in traffic related MVCs. Of this grouping (ISS> 12):

• 70% of the teen drivers were male • 77% of the crashes occurred on rural highways and roadways • 55% of the teen-aged drivers were not wearing seatbelts • One half of the teens tested positive for alcohol

Source: Alberta Child and Teen Major Trauma Report, 2002, p. 25 Note: The next issue of the Alberta Child and Teen Major Trauma Report has not been released to date. In May 2003, the new Graduated Driver Licensing Program started in Alberta with the goal to reduce the injury risk for teens and new drivers. This program has been very successful in other provinces and will hopefully make a difference in this province. Studies have demonstrated that some factors such as driver inexperience, distractibility or reckless attitudes may contribute to the number of collisions among this high risk population of drivers. The program was designed to attempt to address these issues. Source: Alberta Child and Teen Major Trauma Report, 2002, p. 26



MECHANISM OF INJURY - FALLS The number of falls in the adult trauma population continues to rise every year with the highest number in the multi-level category. Comparing age groups for adult males there is very little difference in the numbers; the number of falls for adult females increases with age. Falls remained consistent (28.4% 2003/2004; 27% 2002/2003) in the overall major trauma population at FMC. The number of falls in children rose very high in 1999/2000 (40), dropped in numbers and then started to rise again in 2002/2003 (28). This year, falls made up 27.8% of major paediatric trauma cases (30.1% 2002/2003). In both males and females, there was a rise in falls in the 10-14 year age group. It is important to note that, due to the small sample numbers caution must be taken to generalise findings across the paediatric population. More females fall as they age, but in very young children, more males fall.

FMC - 2003/2004

127

73

44

Multi-level Same Level Other/Unspecified

# of

Pat

ient

s

ACH - 2003/2004

17

9

1

Multi-level Same Level Other/Unspecified

# of

Pat

ient

s

FMC - 5 year falls total trend

183 187 191 207244

99/00 00/01 01/02 02/03 03/04

# of

Pat

ient

s

ACH - 5 year falls total trend

40

19 18

28 27

99/00 00/01 01/02 02/03 03/04

# of

Pat

ient

s

In the Calgary Health Region, the Fall Prevention Program was designed to reduce the incidence and severity of falls in the older adult population. The program provides advice, support and information to patients, families and practitioners. The incidence of falls in the older adult population may be under represented in this data due to the ISS > 12 scoring system for major trauma. Ground level falls are very common and may produce injuries and may be scored ISS < 12 (e.g. hip fractures). For more details regarding the older adult population please see the Gender/Age/Mechanism of Injury Pattern graphs later in this document.



MECHANISM OF INJURY - VIOLENCE Incidents of violence in the FMC major trauma population has remained fairly stable at 107 patients this year compared to 80 last year (12.4% 2003/2004 compared to 10.4% 2002/2003). There was an increase in unarmed assaults from 22.5% (18) in 2002/2003 to 30.8% (33) in 2003/2004. Assaults with an object have remained constant at 45.8% 2003/2004 and 45% 2002/2003. At the FMC, patients with self inflicted violence, has markedly decreased from 26.3% in 2002/2003 to 15% in 2003/2004. This does not include patients who die at the scene of their injury event. The male to female ratio is 7:1 2003/2004, a huge increase from 2:1 in 2002/2003. The Alberta Centre for Injury Control website reported in 1999 that suicide was the leading cause of injury death among Albertans representing one third of all injury fatalities. This issue was identified as a priority in the Alberta Injury Control Strategy (AICS). The AICS was developed by Alberta injury control stakeholders in 2003 and was presented to the Alberta government's Standing Policy Committee on Health and Community Living on November 12, 2003 by the Co-Chairs of the AICS Steering Committee, in search of government support for and adoption of the AICS. Violence characterizes 7.2% of the ACH paediatric major trauma, down from 9.7% in 2002/2003. Unarmed assaults made a dramatic drop from 77.8% (7) in 2002/2003 to 28.6% (2) in 2003/2004. Suicide however, has increased from 22.2% (2) in 2002/2003 to 42.9% (3) in 2003/2004.

FMC 2003/2004

33

49

168

1

Unarmedassault

Assault wit hobject

Self - inf lict ed Unknown t ypeof assault

Ot her assault

# of

Pat

ient

s

ACH 2003/2004

2 2

3

Unarmedassault

Assault w ithobject

Self-inf licted

# of

Pat

ient

s

FMC - 5 year violence total trend

6749

8980

107

99/00 00/01 01/02 02/03 03/04

# of

Pat

ient

s

ACH - 5 year violence total trend

5 5

9 9

7

99/00 00/01 01/02 02/03 03/04

# of

Pat

ient

s

For male children, there is an increase in violence related to injury in the greater than 14 year old age group. Female children show an increase in the 1 to 4 year group and the 10-14 year group. There was a drop in the unarmed assaults from the previous year from 7 (2002-2003) to 2 patients.



MECHANISM OF INJURY – OTHER Mechanical MOI include injuries caused by machinery or a moving object, injuries sustained in or between objects, and injuries sustained when struck by an object or a person. Animal MOI include animal attacks, and injuries sustained while riding, or in other contact with animals. Unknown and Other categories include injuries caused by forces not indicated in the other four categories.

FMC 2003/2004

40

1812

1 17

1 2 3 4 5 6

# of

Pat

ient

s

ACH 2003/200411

3

10

32

1 2 3 4 5 6

# of

Pat

ient

s

Legend 1. Mechanical 2. Animal 3. Fire / explosion / electric 4. Environmental 5. Drowning 6. Unknown

Legend 1. Mechanical 2. Animal 3. Fire/explosion/electrical 4. Environmental 5. Drowning 6. Inhalation

FMC - 5 year other total trend

73

87 87

74

79

99/00 00/01 01/02 02/03 03/04

# of

Pat

ient

s

ACH - 5 year other total trend

8

18

28

13

20

99/00 00/01 01/02 02/03 03/04

# of

Pat

ient

s



GENDER/AGE/MECHANISM OF INJURY PATTERN FMC data from 2003/2004 indicates transportation is the leading cause of injury in both males and females. 48.9% (316) males and 52.8% (113) females sustained injury due to transportation. Of those, 85.4% of males and 77.9% of females are between the ages of 15-54. 26.3% (170) of males were injured in a fall. Of those, 38.8% (66) are >55 years of age. 34.6% (74) of females were injured in a fall with 71.6% >55 years of age. 14.9% of major trauma to males involved violence compared to 4.9% females. Both males & females show the majority of violence related injury occurs in the 15-44 year group (84.4% males; 90% females). There was one noticeable difference in the Fall MOI category related to females age > 65 years of age. The number of females that sustained a fall in 2002-2003 in this age group was 23 patients. The number for 2003-2004 was 46 patients or exactly double the previous year. This raises some questions regarding the impact of an aging population and the need to build on the Fall Prevention strategies within this aging female population. There was no marked difference in the male population in this age group.

Males Females

FMC 2003/2004

0

20

40

60

80

100

120

0-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 >84

# of

Pat

ient

s

Transportat ion Falls Violence Other

Excludes 1 male violence unknown age.

FMC 2003/2004

0

10

20

30

40

50

0-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 >84

# of

Pat

ient

s


Excludes 1 female transportation unknown age. Transportation is the leading cause of injury in children from age 5 on, with the majority of incidents happening between 10-14 years of age, as in the previous year. In both males and females there was a rise in the number of falls in the 10-14 year age group.

Males Females

ACH 2003/2004

-202468

1012141618

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

# of

Pat

ient

s


ACH 2003/2004

0

1

2

3

4

5

6

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

# of

Pat

ient

s




TYPE OF INJURY ‘Type of injury’ categories are used to broadly describe the type of force that results in injury. In both the adult and paediatric population, the majority of injuries are the result of blunt forces. When comparing 2003/2004 to 2002/2003 at the FMC, there is an 11.2% increase in blunt trauma, a 16.7% increase in penetrating trauma, a 44.4% increase in burn related trauma and a 75% increase in other. At the ACH, blunt trauma remained stable, penetrating trauma increased from 0 (2002/2003) to 1 (2003/2004). Burns also increased from 0 (2002/2003) to 1 (2003/2004). Other Injury type represent a 60% increase - 5 (2002/2003) and 8 (2003/2004).

FMC 2003/2004

805

35 13 7

Blunt Penetrating Burn Other

# of

Pat

ient

s

ACH 2003/2004

87

1 18

Blunt Penetrating Burn Other

# of

Pat

ient

s

Blunt Injury

FMC - 5 year trend

573 639734 724

805

99/00 00/01 01/02 02/03 03/04

# of

Pat

ient

s

ACH - 5 year trend

8173

92 87 87

99/00 00/01 01/02 02/03 03/04

# of

Pat

ient

s

Penetrating Injury

FMC - 5 year trend

30

22

3430

35

99/00 00/01 01/02 02/03 03/04

# of

Pat

ient

s

ACH - 5 year trend

0 0 0 0

1

99/00 00/01 01/02 02/03 03/04

# of

Pat

ient

s

Penetrating trauma may not include patients sustaining a single system or single organ injury due to a stabbing incident and may include patients that fall or injure themselves on a sharp object.



Burn Injury

FMC - 5 year trend

12 11

14

9

13

99/00 00/01 01/02 02/03 03/04

# of

Pat

ient

s

ACH - 5 year trend

0

2

1

0

1

99/00 00/01 01/02 02/03 03/04

# of

Pat

ient

s

Other Injury

FMC - 5 year trend

10

78

4

7

99/00 00/01 01/02 02/03 03/04

# of

Pat

ient

s

ACH - 5 year trend

32

5 5

8

99/00 00/01 01/02 02/03 03/04

# of

Pat

ient

s

DIRECT VS TRANSFER Direct means the patient was transported “directly” from the scene to a trauma centre; whereas, transfer means the patient was initially treated at another facility and then “transferred” to a trauma centre. In 2003/2004, 59.4% of patients were transported directly from the scene to the FMC (2002/2003 - 58.1%), and 40.6% were transferred from another facility (2002/2003 - 41.9%). At ACH, 51.5% of patients were transported directly from the scene (compared to 60.2% 2002/2003). 48.5% were transferred from another facility (compared to 39.8% 2002/2003).

Direct vs. Transfer

FMC - 5 year trend

511

349

446444

341367

321346338258

99/00 00/01 01/02 02/03 03/04

# of

Pat

ient

s

Direct Transfer

ACH - 5 year trend

505655

41 4147

3743 37

43

99/00 00/01 00/02 02/03 03/04

# of

Pat

ient

s

Direct Transfer



INTERHOSPITAL TRANSFERS WITHIN CALGARY

FMC interhospital transfers

2833

2

PLC RGH ACH

# of

Pat

ient

s

ACH interhospital transfers

2

1 1

PLC RGH FMC

# of

Pat

ient

s

These patients are the major trauma patients that arrive at one site (e.g. PLC) by ground ambulance, walk-in or private vehicle and are transferred to FMC or ACH. In some cases patients were transferred from ACH (2) or FMC (1) to the alternate trauma centre. GROUND VS AIR TRANSPORT “Ground” refers to ground (road) ambulance transport. “Air” includes fixed wing and rotary wing aircraft. In situations where both modes of transport are utilized to get patients to FMC or ACH, only the air transport portion is represented in this collection of statistics. 73.3% of patients are transported to the FMC Trauma Centre by ground ambulance, a 20.7% (108 patients) increase from 2002/2003. 64.9% of patients transported to the ACH are transported by ground ambulance, an 18.9% (10 patients) increase from 2002/2003. Air transports for FMC decreased by 1%, while air transports to ACH decreased by 21.4%.

Ground vs Air

FMC - 5 year trend

630

201

388 416489 522

211 228 255203

99/00 00/01 01/02 02/03 03/04

# of

Pat

ient

s

Ground Air

ACH - 5 year trend

63

22

5352

39 39

2630 2825

99/00 00/01 01/02 02/03 03/04

# of

Pat

ient

s

Ground Air

Private vehicle/walk-in: 27 Private vehicle/walk-in: 11 Unknown mode of arrival: 2 Unknown mode of arrival: 1



DIRECT FROM SCENE BY GROUND VS ROTARY WING

FMC Ground vs Rotary Wing

412

72

Ground Rotary Wing#

of P

atie

nts

Excludes patients arriving via private vehicle/walk in

ACH - Mode of Arrival, 2003/2004INSIDE / OUTSIDE CALGARY

33

1 0 3

19 146 1

111 0

7

Ground STARS Fixed Wing Private Vehicle/walkin

# of

Pat

ient

s

Inside Calgary Outside Calgary Unknown

Excludes 1 patient with unknown mode of arrival from outside of Calgary. PHYSICIAN SERVICE ANALYSIS The majority of trauma patients at the FMC site are admitted under the services of the general surgeon, followed by the intensivist. General surgery admissions from previous years were 2002/2003 - 385, 2001/2002 - 306. “Other” includes hospitalists at the FMC site. This analysis does not include transfers of care, nor consulting services. At the ACH, the ICU service is responsible for the majority of trauma admissions, followed by paediatrics (includes hospital-based paediatricians). In previous years, ICU admissions were 2002/2003 - 35, 2001/2002 - 47.

FMC 2003/2004

385

205156

4912 1 1 30

GS ICU NS OS PS OB/GYN Thor Other

# of

Pat

ient

s

ACH 2003/2004

48

16 169

5 2

ICU Ped Ped Surg OS NS PS

# of

Pat

ient

s

Legend: GS - general surgery; ICU - intensive care unit; NS - neurosurgery; OS - orthopaedic surgery; PS - plastic surgery; OB/GYN - obstetrics and gynecology; Thor - thoracic; Ped - paediatrician; Ped surg - paediatric surgery



SURGICAL PROCEDURES In 2003/2004, physicians performed 933 surgical procedures on major trauma patients at the FMC. The procedures were done during 581 visits to the operating rooms, requiring 1500 operating room hours. While this is a 11.4% decrease from the number surgical procedures compared to 2002/2003 (1053), there is little difference in the number of operating room visits (583) or operating room hours (1499). In 2003/2004 at the ACH, 55 surgical procedures were performed on major trauma patients during 37 operating room visits, totalling 80 operating room hours. While there were 9.8% less procedures performed than in 2002/2003 (61) however, 2003/2004 had more operating room visits (2002/2003 - 33) requiring more operating hours (2002/2003 - 65).

FMC 2003/2004364

226 218

100

11 6 2 1 1 4

OS PS GS NS Thor CV OB/G Opth Urol Other

# of

Pro

cedu

res

ACH 2003/200414

8

46

1

6

Ortho Plastics Ped Surg NS Urology Other#

of P

roce

dure

s

Legend: CV - cardiovascular; Thor - thoracic; Opth - ophthalmology; OB/G - obstetrics & gynecology; Ortho - 0rthopedics; Ped Surg - paediatric surgery; NS - neurosurgery; PS - plastic surgery; Other - anesthesia, radiology, etc.

There was a decrease in the orthopaedic procedures performed at FMC from 424 (2002-2003) however, orthopaedics continues to be the highest number of surgical procedures performed at FMC and ACH. ICU TRAUMA ADMISSIONS In 2003/2004, 29.5% (34.4% 2002/2003) of major trauma admissions were admitted to the FMC ICU. At ACH, 54.6% of major trauma admissions were admitted to the ICU (38.7% 2002/2003).

FMC 2003/2004

17

28

20

34 36

2418 19

10

23

1114


# of

Adm

issi

ons

ACH 2003/2004

5

3

56

9

54

2

4

6

3

1


# of

Adm

issi

ons

Total ICU trauma admissions at the FMC were 254 patients. Nine of the 254 ICU admissions were ICU readmissions and 1 was a third ICU admission. Six of the readmissions were unplanned. All unplanned ICU admissions and readmissions are reviewed as part of the trauma quality improvement process. FMC Trauma ICU admissions comprised 23.4% of the total overall ICU admissions of 1087 for the fiscal year. The total ICU admissions at the ACH were 53. 1 of the ICU admissions was unplanned. There was 1 ICU readmission however, this was planned.



ICU TRAUMA ADMISSIONS cont.

FMC - 5 year trend

260

245

287

264254

99/00 00/01 01/02 02/03 03/04

# of

Adm

issi

ons

ACH - 5 year trend

50 46 50

36

53

99/00 00/01 01/02 02/03 03/04

# of

Adm

issi

ons

MEDIAN ICU LOS FOR TRAUMA PATIENTS Medians provide a better evaluation of LOS for comparison purposes; averages are greatly affected by the ranges of LOS, particularly by extended LOS.

FMC - 5 year trend

4 4 4 4.5 4

99/00 00/01 01/02 02/03 03/04

All Patients

# of

Day

s

ACH - 5 year trend

1

2 2

1 1

00/01 01/02 02/03 02/03 03/04

All Patients

# of

Day

s

All patients range 1-71 days Average 8 Standard deviation (SD) 9.6 02/03 average 9

All patients range 1-32 days Average 3.4 Standard deviation (SD) 5.5 02/03 average 2.7

The median ICU LOS decreased from 4.5 to 4 at the FMC ICU. Improved access and patient flow is a priority issue for the Calgary Health Region quality improvement initiatives. At FMC access to ICU beds has presented many challenges over the last year. In some cases, patients had to be transferred from FMC ICU to other acute care sites to accommodate the admission of the trauma patient. Processes and policies regarding interfacility transfers between sites are well established. In other cases the patients wait in Post Anesthetic Recovery Room (PAAR) for an ICU bed. The Regional “no-diversion policy” is strictly upheld for trauma patients. The median ICU LOS at the ACH remained the same for 2003/2004. There we 29 patients with 1 day ICU LOS in 2003/2004. Breakdown of ICU LOS for the other patients is as follows: 7 patients (2 days); 4 patients (3 days); 5 patients (4 days); 1 patient (6 days); 1 patient (7 days); 1 patient (8 days); 1 patient (11 days); 1 patient (16 days); 1 patient (21 days); 1 patient (32 days). ICU readmission LOS for 1 patient was 1 day. Access to ICU beds at ACH can present many challenges.



MEDIAN HOSPITAL LOS The median hospital LOS has demonstrated little to no change over the past 5 years. This included the acute phase of the hospital stay at FMC, not the rehabilitation phase, which can range from days to months.

FMC - 5 year trend9

8 8 8 8

99/00 00/01 01/02 02/03 03/04

All Patients

# of

Day

s

ACH - 5 year trend

5 5 5 5 5

99/00 00/01 01/02 02/03 03/04

All Patients

# of

Day

s

All patients range 1-286 days Average 14.8 Standard deviation (SD) 22.5 02/03 average 15

All patients range 1-113 days Average 9.3 Standard deviation (SD) 16.7 02/03 average 8

OUTCOMES BY AGE The literature states that, generally, outcomes for older adults (65+) or the very young trauma patient (<1) are poor. This is supported by current trauma registry statistics for the older adults (65+). In 2003/2004, there was a decrease in the percentage of older adult trauma patients who died from injuries sustained (18.7%), compared to 2002/2003 (19.6%). Of the younger adult age groups (< 65), 7.9% died (10.5% in 2002/2003). At ACH, the 1-4 age group experienced the highest mortality (25%). In 2002/2003, 16.7% died in this age group.

FMC 2003/2004

4

203

128 125 138

49 54 561613 88680 18 9 15

0-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 >84

# of

Pat

ient

s

Survivors Non-survivors

ACH 2003/2004

6

16 16

35

17

1 4 1 1 0

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

# of

Pat

ient

s


Excludes 2 patients with unknown age.



OUTCOMES BY MAJOR MECHANISM OF INJURY At the FMC, falls claimed the highest % of lives (11.1%) followed by violence (10.3%), then other (10.1%) and lastly transportation at 9.5%. At the ACH, mortality was highest in the violence category at 28.6%. This was followed by other at 10%, transportation at 7%. No deaths occurred in the falls category.

FMC 2003/2004

389

217

96 7141 27 11 8


# of

Pat

ient

s


ACH 2003/2004

40

27

5

18

3 0 2 2


# of

Pat

ient

s


OUTCOMES BY ISS The higher the ISS, the higher the risk of mortality. This is supported by the line graphing mortality trends at both FMC & ACH. There were no patients at ACH with an ISS greater than 45.

146

438

142

349 4 01

43 25 11 4 1 20

50

10 0

150

2 0 0

2 50

3 0 0

3 50

4 0 0

4 50

50 0

12-15 16-25 26-35 36-45 46-55 56-65 66-75

# of

pat

ient

s

0

2 0

4 0

6 0

8 0

10 0

12 0

% M

orta

lity

Survivo rs N o n-survivo r T rend Line

18

57

14

104

1 2 0 0 00 000

10

2 0

3 0

4 0

50

6 0

12-15 16-25 26-35 36-45 46-55 56-65 66-75

# of

pat

ient

s

0

10

2 0

3 0

4 0

50

6 0

70

8 0

% M

orta

lity

Survivors Non-survivor Trend Line

YEARLY OUTCOMES BY SURVIVORS/NON-SURVIVORS The mortality rate at FMC (10.1%) has decreased slightly when compared with 2002/2003 (11.9%). Mortality rate at ACH (7.2%) has decreased since 2002/2003 as well (9.6%).

FMC - 5 year trend

531 598 698 675 773

94 81 92 92 87

99/00 00/01 01/02 02/03 03/04

# of

Pat

ient

s


ACH - 5 year trend

75 7187 84 90

9 7 11 9 7

99/00 00/01 01/02 02/03 03/04

# of

Pat

ient

s




DISCHARGE LOCATION The majority of trauma patients from both sites are discharged “home”. From the documentation in the chart, it is often difficult to determine which, if any, support services may be provided at “home”; therefore “home with support” may be under represented. The unknown category represents the number of patients for which no specific discharge location was documented in the chart.

FMC 2003/2004469

12079 52

10

8743

Home Rehab AcuteCare

Home /Support

Nursing /Chronic

Care

Died Other /Unknown

# of

Pat

ient

s

ACH 2003/2004

81

0 1 5 07 3

Home Rehab Acute Care Home /Support

Nursing /Chronic

Care

Died Other /Unknown

# of

Pat

ient

s

NOTE: The ACH does not have a dedicated rehabilitation unit. 4 dedicated rehabilitation beds are planned for the new ACH site opening in 2006.

ISS ≥ 16 TRAUMA TOTALS In 1992, the inclusion criteria for the Trauma Registry was ISS ≥ 16. In 1993, this was revised to an ISS ≥ 12. The following graph depicts a 5 year span of patients with an ISS ≥ 16.

FMC - 5 year trend

530 549648 627

713

99/00 00/01 01/02 02/03 03/04

ISS = 16

# of

Pat

ient

s

ACH - 5 year trend

59 6386

76 79

99/00 00/01 01/02 02/03 03/04

ISS = 16

# of

Pat

ient

s

At FMC, there has been a 34.5% increase in the number of patients with an ISS ≥ 16 over the last 5 years (99/00 - 530). This is a similar pattern at the ACH where there was a 33.9% increase in 2003/2004 when compared to 1999/2000. This rise in major trauma cases has resulted in increased pressures on acute care and community resources, with demands for improvements in performance, technology and efficiency measures. Regional Trauma Services, in partnership with various acute care and community groups, plays a lead role in supporting providers to meet the challenges and ensure quality, effective care for trauma patients and their families throughout the system.

Trauma Statistics & Outcome Data April 1, 2003 - March 31, 2004

Peter Lougheed Centre Rockyview General Hospital

Submitted by: Dianne Dyer, Manager Regional Trauma Services Calgary Health Region


Stats & Outcomes - PLC & RGH 44

Quality Improvement Processes: Peter Lougheed Centre (PLC) and Rockyview General Hospital (RGH) Three strategies were used to manually collect data and evaluate trauma care at the PLC/RGH sites: 1. Review of injury discharge lists prepared by Quality Improvement Health Information (QIHI). Trauma

patients with an ISS ≥ 12 and/or patients who experienced system issues were identified and the case was reviewed at the quarterly trauma committee meetings at the specific site.

2. Management and staff at both sites were encouraged to complete a trauma follow-up form in emergency with information on the traumatically injured patient. These forms were collected each month and the charts were reviewed. Any issues were brought to the site trauma committee, or addressed as quickly as possible with the specific department.

3. Cases were referred directly to Regional Trauma Services for immediate review of trauma issues.

To support the accuracy and comprehensive quality improvement processes at RGH and PLC, Regional Trauma Services submitted a proposal for Trauma Registry software for these two additional sites. In the new model, the Trauma Registry data would be forwarded to a central site at FMC for reporting purposes. Approvals were received for the funding.

# of charts reviewed TOTAL: 351 (April 1st 2003 - March 31st 2004) Reviews: PLC (2 meetings), RGH (3 meetings)

# of follow-up form referral cases with ISS > 12 Note: All patients were admitted and discharged from these sites.

106

243

PLC RGH

3

2

PLC RGH

# of discharged cases (QIHI data) with ISS > 12 Note: All patients were admitted and discharged from these sites.

# of males / females at each site

19

28

PLC RGH

14

19

8

11

PLC RGHMales Females

The RGH and PLC Trauma Committees reviewed all of the major trauma admissions (ISS ≥ 12). All of the admissions were assessed as appropriate admissions to the sites. In some cases, specific site issues or challenges were identified and referred to the specific departments for follow-up.



Age of patients

0 0

1

0

2 2

5

2

4

0 0 0

1

2

7

6

5

1 1

4

2

3

22

< 1 1-4 5-15 16-17 18-24 25-34 35-44 45-54 55-64 65-74 75-84 > 84

PLC RGH

Mechanism of injury ISS ≥ 12 Mode of arrival ISS ≥ 12

5

11

42

5

24

1 0


PLC RGH

17

41

24

6

0

EMS Private Vehicle Other (police)

PLC RGH

ICU admissions ISS ≥ 12

Transfers to other sites

4 4

PLC RGH

ISS (unknown at time of transfer)14

1

7

0

FMC ACH

PLC RGH



The following table summarizes the injury data, based on injury discharge codes provided by QIHI, for the fiscal year 2002 - 2003 vs. 2003 - 2004.

2002-2003 2003-2004 Sites Injury

Discharges ISS ≥ 12 Injury

Discharges ISS ≥ 12

FMC 3570 772 3532 860 ACH 872 93 696 97 PLC 1557 22 1525 22 RGH 1872 22 2017 30 Total 7871 909 7770 1009

Traumatic Injury Discharges >18 years by site and month (QIHI)

# of

pat

ient

s

FMC 299 272 297 359 320 301 278 234 278 274 235 262

PLC 94 125 115 136 128 102 139 114 114 127 135 124

RGH 144 154 174 179 170 160 161 155 184 158 172 164


The number of traumatic injury discharges for this age group at FMC was consistently high ranging from 234 patients in November to 359 patients in July. The ability to accurately predict peaks in adult trauma patient numbers and therefore staffing resources is not very reliable and can present significant challenges at FMC.

Traumatic Injury Discharges Ages 0-18 years by site and month (QIHI)

# of

pat

ient

s

ACH 51 71 37 82 90 71 62 44 65 39 37 47

FMC 6 19 8 15 7 11 9 8 12 10 8 10

PLC 6 12 4 7 7 4 10 6 3 4 4 5

RGH 1 7 1 5 6 5 5 3 4 0 1 4


Foothills Medical Centre Performance Indicators Submitted by: Ms. Christi Findlay, Data Analyst Regional Trauma Services Calgary Health Region


Performance Indicator - FMC 48

Foothills Medical Centre PERFORMANCE INDICATORS

As part of the Regional Trauma Services quality improvement process, several 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 Southwestern Sydney Region Trauma Department, Liverpool, Australia. Other indicators were developed at FMC and ACH as site specific performance indicators. The following is a summary of these indicators at FMC for patients who meet the inclusion criteria for the Alberta Trauma Registry (patients with an ISS > 12 and who are admitted to the hospital or die in the ED at the FMC). Each performance indicator number is based on the specific determinant of the indicator within the total of 860.

PRE-HOSPITAL PHASE

GCS (Glasgow Coma Scale) ≤8 at Scene / Mechanical Airway

Did the patient with a first recorded scene GCS ≤ 8 receive mechanical airway as an intervention at the scene? Mechanical airway includes intubation (nasal and oral), cricothyroidotomy and tracheostomy.

Indicator Yes No

2003/2004, n = 121 57 64

2002/2003, n = 129 61 68

2001/2002, n = 136 71 65

47.352.2 47.1

47.8 52.7 52.9

2001/2002 2002/2003 2003/2004

%Yes %No

n = all patients with first recorded scene GCS ≤8.

INTERHOSPITAL TRANSFERS within Calgary

Transfers from PLC/RGH/ACH to FMC trauma centre; may have been from a primary or secondary hospital site.

Peter Lougheed Centre Total Injury Discharges 2003-2004 = 1525 Was the ISS > 12 patient transferred from the PLC to the FMC trauma centre?

Indicator Yes No

2003/2004, n = 349 28 321

2002/2003, n = 321 24 297

2001/2002, n = 346 23 323

7.57 8

93 92.5 92

2001/2002 2002/2003 2003/2004

%Yes %No

n = all patients transferred from another hospital.



Rockyview General Hospital Total Injury Discharges 2003-2004 = 2017 Was the ISS > 12 patient transferred from the RGH to the FMC trauma centre?

Indicator Yes No

2003/2004, n = 349 33 316

2002/2003, n = 321 19 302

2001/2002, n = 346 16 330

5.94.6 9.5

95.4 94.1 90.5

2001/2002 2002/2003 2003/2004

%Yes %No

n = all patients transferred from another hospital

Alberta Children’s Hospital Total Injury Discharges 2003-2004 = 696 Was the ISS > 12 patient transferred from the ACH to the FMC trauma centre?

Indicator Yes No

2003/2004, n = 349 2 347

2002/2003, n = 321 3 318

2001/2002, n = 346 0 346

0.61

99.499100

2001/2002 2002/2003 2003/2004

%Yes %No

n = all patients transferred from another hospital

INTERHOSPITAL TRANSFERS outside Calgary

Time Spent at Sending hospital Did the patient spend < 2 hours at the sending hospital prior to transfer to FMC trauma centre?

Indicator Yes No

2003/2004, n = 243 101 142

41.6

58.4

2003/2004

%Yes %No

n= all patients transferred from a sending hospital outside Calgary, with a known sending hospital LOS.

NOTE: This is a new indicator combining primary and secondary hospitals into “sending” hospital. 24 patients had a primary and a secondary hospital. A goal for the future is to send out letters to the sending physician with pertinent timely patient outcome information compliant within the Freedom of Information and Privacy Act (FOIP) and the Health Information Act (HIA). 24 patients had a primary and a secondary hospital.



District Centre Transfers Was the patient transferred from proposed district trauma centres?

Indicator Yes No

2003/2004, n = 286 84 202

2002/2003, n = 275 63 212

2001/2002, n = 309 68 241

22.922 29.4

78 77.1 70.6

2001/2002 2002/2003 2003/2004

%Yes %No

n = all patients transferred from hospital outside Calgary In the Alberta Centre for Injury Control and Research (ACICR) Provincial Proposal (June, 2001) five centres were identified as proposed District Trauma Centres: Lethbridge Regional Hospital, Medicine Hat Regional Hospital, Red Deer Regional Hospital, Queen Elizabeth II Hospital, Grande Prairie, and Northern Lights Regional Hospital, Fort McMurray. The goal of the Provincial Proposal is to develop and maintain an organised, integrated provincial trauma system that is cost effective while reducing mortality and morbidity due to injury. This model aims to get "the injured person to the right treatment at the right trauma facility in the shortest time". (Source: Provincial Trauma System: Proposal for Alberta (2001, June), Alberta Centre for Injury Control & Research, p. 1) In the proposal, each identified District Centre strives to become a Trauma Association of Canada accredited trauma centre, which includes the establishment of a trauma team, a trauma registry and adequate educational and equipment resources. NEW INDICATOR

Injury Time to Trauma Centre If the patient was transferred from a hospital outside Calgary, was it less than 4 hours from injury time to arrival at FMC Trauma Centre?

Indicator Yes No

2003/2004, n = 161 54 107

33.5

66.5

2003/2004

%Yes %No

n= all patients transferred from a hospital outside Calgary with a known time of injury event and known time of arrival to FMC Trauma Centre



Out of Province Transfers Was the patient, whose home address was not in Calgary, transferred from out of province? Of the 40 out of province transfers (whose home address was not Calgary), 82.5% (33) were transferred from British Columbia hospitals.

Indicator Yes No

2003/2004, n = 270 40 230

2002/2003, n = 238 48 190

2001/2002, n = 288 57 231

20.219.8 14.8

80.2 79.8 85.2

2001/2002 2002/2003 2003/2004

%Yes %No

n = all patients transferred from a hospital outside of Calgary with patient home address outside of Calgary.

RESUSCITATIVE PHASE Trauma Team Activations At FMC, activation of the trauma team is initiated at the discretion of the ED physician, or through the pre-hospital process of communication. The activation criteria are based on the Gold Book, published by the American College of Surgeons Committee on Trauma, with input from the American College of Emergency Physicians. The criteria for automatic trauma team activation (TTA), (level 1), are:

1. confirmed shock, defined as BP systolic < 90 or temp < 28° 2. intubated patient or patient with respiratory compromised obstruction 3. patient with a GCS < 8 4. gunshot wound to the head, neck or trunk 5. need for blood transfusion en route to hospital

Proposed changes to #2 and #5 above were initiated following Adult Trauma Care Committee approvals in the summer of 2003. 2. intubated patient en route or in the emergency department or patient with respiratory compromise 5. need for blood transfusion en route or in the emergency department In cases of significant mechanism or obvious significant injury to patients who do not meet these criteria, early discussion/consultation with the trauma surgeon/service and the trauma resident is recommended to ensure timely intervention. The second level of activation is consult only.

The above graph illustrates trauma team activation for the major trauma population only (ISS ≥12). There are instances where the trauma team is activated and the patient injury severity score is <12. In 2003/2004 there were 429 documented trauma team activations in total, 235 patients were classified as major trauma (ISS ≥ 12).

19

12

19

27

22

14

97

18

12

2523

26

1915

27 26

17

28

35

22

129

14


# of

Act

ivat

ions

2002/2003 2003/2004



Trauma Team Leader (TTL) Response Time Was the TTL response time < 20 minutes?

Indicator Yes No

2003/2004, n = 210 202 8

2002/2003, n = 196 181 15

2001/2002, n = 231 209 22

92.390.5 96.2

9.57.7 3.8

2001/2002 2002/2003 2003/2004

%Yes %No

n = all patients with trauma team activation and a known trauma team leader response time (excludes direct admits) Unknown trauma team response times (25) excluded from response time analysis.

Excludes direct admits Indications:

1. confirmed shock defined as BP systolic < 90 or temp < 280 2. Intubated patient en route or in the emergency department or patient with respiratory compromise 3. patient with a GCS < 8 4. gunshot wound to the head, neck or trunk 5. need for blood transfusion en route or in the emergency department Revised at the Adult Trauma Care Committee meeting in June 2003 The Trauma Team may be activated by the triage nurse, the emergency physician or the nurse clinician prior to arrival of the patient, or upon arrival of the patient to the Trauma Centre. Charts are reviewed when the TTA criteria are met and the trauma team is not activated and/or the Trauma Team Leader response exceeds 20 minutes. In this year, of the 75 cases in which the criteria were met but the team was not activated, 32 or 42.7% were single system head injured patients.

TTA Criteria Met27.3% (226)

TTA Criteria Not Met 72.7% (601)

Yes, TT Activated14% (84)

No, TT Not Activated 86% (517)

Response Time Within 20 Min?

Yes, TT Activated 66.8% (151)

No, TT Not Activated33.2% (75)

Response Time Within 20 Min?

Yes 86.1% (130)

No 2.6% (4)

Unknown Response Time

11.3% (17)

Yes85.7% (72)

No4.8% (4)

Unknown Response Time

9.5% (8)

Trauma Team Activation (TTA) Criteria



GCS < 8 Mechanical Airway in ED

Did the patient with a first recorded trauma centre GCS < 8 receive a mechanical airway as an intervention in the FMC ED? Mechanical airway includes intubation (oral, nasal, cricothyroidotomy and tracheostomy).

Indicator Yes No

2003/2004, n = 40 34 6

2002/2003, n = 33 27 6

2001/2002, n = 25 17 8

81.86885

32 18.2 15

2001/2002 2002/2003 2003/2004

%Yes %No

n = all patient with 1st recorded trauma centre GCS ≤ 8.

ED Length of Stay (LOS) Did the patient have an FMC ED length of stay (LOS) < 4 hours? Median ED LOS: 5.2 hours Average ED LOS: 7.3 hours Range: 0 to 57.6 hours

Indicator Yes No

2003/2004, n = 798 299 499

2002/2003, n = 714 311 403

2001/2002, n = 749 374 375

43.649.9 37.5

50.1 56.4 62.5

2001/2002 2002/2003 2003/2004

%Yes %No

n = all patient seen in FMC ED with a known LOS.

Joint Reduction Was the joint dislocation reduced within 1 hour of arrival to the FMC trauma centre? ‘Joint’ includes hip, shoulder, ankle, knee and/or elbow.

Indicator Yes No

2003/2004, n = 35 18 17

2002/2003, n = 16 5 11

2001/2002, n = 36 18 18

31.350 51.4

5068.8

48.6

2001/2002 2002/2003 2003/2004

%Yes %No

n = all patients with a hip, shoulder, elbow, ankle or knee dislocation with a hospital LOS ≥ 1 hour and a known reduction time.



CT of the Head

If the patient had a GCS < 13, was a CT of the head performed within 4 hours of arrival to the FMC trauma centre?

Indicator Yes No

2003/2004, n = 62 59 3

2002/2003, n = 58 55 3

2001/2002, n = 37 31 6

94.883.8 95.2

16.2

5.2 4.8

2001/2002 2002/2003 2003/2004

%Yes %No

n = all patients with a known FMC ED GCS and a known time of CT head.

DEFINITIVE CARE PHASE

Craniotomy If the patient had an epidural or subdural brain hematoma, was a craniotomy performed within 4 hours of arrival at the FMC trauma centre? There was 76% increase in the number of craniotomies performed that qualified for the indicator (44: 2003-2004, 25: 2002-2003)

Indicator Yes No

2003/2004, n = 44 38 6

2002/2003, n = 25 21 4

2001/2002, n = 45 42 3

84 86.493.3

13.616

6.7

2001/2002 2002/2003 2003/2004

%Yes %No

n= all patients with epidural or subdural hematoma where operative management was the planned intervention.

Gunshot Wound to Abdomen Was the abdominal gunshot wound managed operatively?

Indicator Yes No

2003/2004, n = 1 1 0

2002/2003, n = 1 1 0

2001/2002, n = 0 N/A N/A

100 100

0

2001/2002 2002/2003 2003/2004

%Yes %No

n = all patients with abdominal gunshot wound admitted to FMC Trauma Centre.



Femur Fracture Did the patient have operative management of the femur fracture within 24 hours of arrival to FMC trauma centre? There was a 70.9% increase in the number of patients qualifying for this indicator this year.

Indicator Yes No

2003/2004, n = 53 51 2

2002/2003, n = 31 25 6

2001/2002, n = 55 50 5

80.690.9 96.2

9.1 19.43.8

2001/2002 2002/2003 2003/2004

%Yes %No

n= all patients with operative management of femur fracture.

Open 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 FMC trauma centre?

Indicator Yes No

2003/2004, n = 40 36 4

2002/2003, n = 40 33 7

2001/2002, n = 54 49 5

82.590.7 90

9.3 17.5 10

2001/2002 2002/2003 2003/2004

%Yes %No

n= all patients with operative management of open fracture.

Unplanned Return to OR Did the patient have an unplanned return to the operating room within 48 hours of the initial procedure at the FMC trauma centre?

Indicator Yes No

2003/2004, n = 374 3 371

2002/2003, n = 337 11 326

2001/2002, n = 398 5 393

3.31.3 0.8

98.7 96.7 99.2

2001/2002 2002/2003 2003/2004

%Yes %No

n = all patients with at least one operating room visit.



Admitting Physician Was the patient admitted under a surgeon or intensivist at the FMC trauma centre?

Indicator Yes No

2003/2004, n = 838 809 29

2002/2003, n = 740 718 22

2001/2002, n = 764 752 12

9798.4 96.5

1.6 3 3.5

2001/2002 2002/2003 2003/2004

%Yes %No

n = all patients admitted to FMC Trauma Centre. NOTE: Excludes patient admitted for palliative care.

Delayed Diagnosis/Missed Injury Did the patient have a delayed diagnosis or missed injury during hospitalisation at the FMC trauma centre? Of the missed injuries, 62.5% were extremity, 18.8% were spinal, 12.5% were thorax, and 6.2% were facial.

Indicator Yes No

2003/2004, n = 839 16 823

2002/2003, n = 741 32 709

2001/2002, n = 764 46 718

4.36 1.9

94 95.7 98.1

2001/2002 2002/2003 2003/2004

%Yes %No

n = all patients admitted to FMC Trauma Centre.

Missed C-Spine Injury Was there a missed c-spine injury with c-spine precautions removed at the FMC trauma centre? 12.7% of total major trauma admissions had a c-spine injury. 0.1% of all major trauma patients experienced a missed c-spine injury with cervical spine precautions removed.

Indicator Yes No

2003/2004, n = 839 1 838

2002/2003, n = 741 2 739

2001/2002, n = 764 4 760

0.30.5 0.1

99.5 99.7 99.9

2001/2002 2002/2003 2003/2004

%Yes %No




Unplanned ICU Admission Was there an unplanned ICU admission at the FMC trauma centre? Most unplanned admissions were due to respiratory compromise. There was a 45.2% decrease in the number of unplanned ICU admissions this year, 254 major trauma patients were admitted to the ICU in 2003-2004, 23.4% of all ICU admissions.

Indicator Yes No

2003/2004, n = 839 17 822

2002/2003, n = 741 31 710

2001/2002, n = 764 18 746

4.22.4 2

97.6 95.8 98

2001/2002 2002/2003 2003/2004

%Yes %No


Unplanned ICU Readmission Did the patient have an unplanned readmission to ICU at the FMC trauma centre? Most unplanned readmissions were due to respiratory compromise. There was 9 readmissions however, 3 of the admissions were planned.

Indicator Yes No

2003/2004, n = 245 6 239

2002/2003, n = 252 10 242

2001/2002, n = 267 15 252

45.6 2.4

94.4 96 97.6

2001/2002 2002/2003 2003/2004

%Yes %No

n = all patients with at least one ICU admission.

Ischemic Limb Was the ischemic limb revascularized at the FMC trauma centre, within 6 hours of injury? Patient must have penetrating wound to an artery or severe fracture where the limb is pulseless. Attempts to reduce the limb have failed and the patient has gone to the OR for vascular repair (shunt, graft or amputation).

Indicator Yes No

2003/2004, n = 5 4 1

2002/2003, n = 2 2 0

2001/2002, n= 7 7 0

10080

100

20

2001/2002 2002/2003 2003/2004

%Yes %No

n = all patients with ischemic limb and LOS ≥ 6 hours stable enough for OR.



Thromboembolic (DVT) Prophylaxis Did the immobile patient receive documented thromboembolic prophylaxis within 24 hours of admission at the FMC trauma centre? Dedicated pneumatic pumps and stockings were ordered for Unit 71, the FMC Trauma Unit to ensure prompt access to equipment. All patients receive stockings unless otherwise ordered by the physician. Indicator Yes No

2003/2004, n = 511 413 98

2002/2003, n = 495 380 115

2001/2002, n = 533 393 140

76.8 80.873.7

19.223.226.3

2001/2002 2002/2003 2003/2004

%Yes %No

n = all immobile patients whose LOS ≥ 24 hours.

Major Facial Fracture Did the patient receive operative management of major facial fractures (mandible, maxilla or orbit) at the FMC trauma centre, within 7 days of injury?

Indicator Yes No

2003/2004, n = 43 40 3

2002/2003, n = 43 42 1

2001/2002, n = 58 56 2

97.796.6 93

3.4 2.3 7

2001/2002 2002/2003 2003/2004

%Yes %No

n = all patients who have operative intervention of major facial fracture.

Spinal Fracture Did the patient receive operative management of spinal fractures at the FMC trauma centre, within 7 days of injury?

Indicator Yes No

2003/2004, n = 44 39 5

2002/2003, n = 38 33 5

2001/2002, n = 44 42 2

86.895.5 88.6

4.513.2 11.4

2001/2002 2002/2003 2003/2004

%Yes %No

n = all patients who have operative intervention of spinal fracture.



Laparotomy Categories Includes all patients with suspected intra-abdominal injury requiring a laparotomy. Patients were categorized based on the following criteria: Category 1: Hemorrhagic shock. Time to laparotomy < 1 hour. Patients with a blood pressure, systolic < 90 in the trauma room, confirmed, or a need for > 4 units of packed red blood cells in the first hour, for hemorrhage due to injury. Category 2: Hemodynamically stable patients requiring emergency laparotomies. Time to laparotomy < 4 hours. Patients who present with truncal injury requiring emergency laparotomy who do not meet criteria for shock. Transfusion requirements are < 4 units in the first hour. BP systolic is > 90. Typically, these represent patients with injuries identified at the time of CT scanning. Category 3: Patients requiring delayed laparotomy. Patients for whom acute indications for emergency laparotomy were not identified at the time of initial trauma assessment and resuscitation (i.e., patients with stable visceral injury with delayed development of bleeding, or patients with occult intra-abdominal injuries, diagnosed after admission).

Category 1 Laparotomies If the patient received a category 1 laparotomy, was it performed within 1 hour of arrival to FMC trauma centre? 2003/2004 average time to lap: 57.1 min median time to lap: 47 min 2002/2003 average time to lap: 115.5 min median time to lap: 89.5 min Indicator Yes No

2003/2004, n = 33 23 10

2002/2003, n = 16 8 8

2001/2002, n = 31 24 7

5077.4 69.7

22.650

30.3

2001/2002 2002/2003 2003/2004

%Yes %No

n = all patients with Category 1 laparotomy. Of patients requiring category 1 laparotomy, and laparotomy was not performed within 1 hour of arrival to trauma centre 90% had laparotomies within 2 hours.

Category 2 Laparotomies If the patient received a category 2 laparotomy, was it performed within 4 hours of arrival to FMC trauma centre? 2003/2004 average time to lap: 143.4 min median time to lap: 109 min 2002/2003 average time to lap: 173.7 min median time to lap: 170 min Indicator Yes No

2003/2004, n = 17 13 4

2002/2003, n = 18 14 4

2001/2002, n = 33 24 9

77.872.7 76.5

27.3 22.2 23.5

2001/2002 2002/2003 2003/2004

%Yes %No

n = all patients with Category 2 laparotomy.



Therapeutic Laparotomies: Category 1 If the patient required laparotomy at the FMC trauma centre, was the laparotomy therapeutic? Therapeutic laparotomy is defined as discovery of an injury that requires suturing or packing.

Indicator Yes No

2003/2004, n = 33 29 4

2002/2003, n = 14 14 0

2001/2002, n = 31 28 3

90.3 100 87.9

9.7 12.1

2001/2002 2002/2003 2003/2004

%Yes %No



Indicator Yes No

2003/2004, n = 17 15 2

2002/2003, n = 18 17 1

2001/2002, n = 33 29 4

87.9 94.4 88.2

12.15.6

11.8

2001/2002 2002/2003 2003/2004

%Yes %No



Indicator Yes No

2003/2004, n = 15 13 2

2002/2003, n = 15 14 1

2001/2002, n = 15 13 2

90.3 93.3 86.7

9.7

6.7

13.3

2001/2002 2002/2003 2003/2004

%Yes %No




OUTCOMES

Death during First 24 Hours Did the patient die within the first 24 hours of arrival to the FMC trauma centre?

Indicator Yes No

2003/2004, n = 87 53 34

2002/2003, n = 92 51 41

2001/2002, n = 92 49 43

53.3 55.4 60.9

46.7 44.6 39.1

2001/2002 2002/2003 2003/2004

%Yes %No

n= all patients who die.

Mortality Did the patient die at the FMC trauma centre?

Indicator Yes No

2003/2004, n = 860 87 773

2002/2003, n = 767 92 675

2001/2002, n = 790 92 698

10.11211.6

88.4 88 89.9

2001/2002 2002/2003 2003/2004

%Yes %No

n = all patients arriving at FMC trauma centre.



Trauma Score Injury Severity Score (TRISS) Methodology TRISS methodology uses logistic regression to predict survival based on the Revised Trauma Score (RTS), injury severity score (ISS), mechanism of injury (blunt vs. penetrating) and patient age. Unexpected deaths are trauma patients with a predicted probability of survival of 0.5 or more that die and unexpected survivors are trauma patients with a predicted probability of survival of 0.49 or less that survive. TRISS ‘z’ statistic measures the statistical significance of the difference between the actual number of survivors among a set of patients and the number of survivors expected from outcome norms. W measures the clinical significance of the differences between the actual and unexpected survivors. W is the number of survivors more than would be expected from the outcome norms per 100 patients treated. W can be calculated if the z score is greater than 1.96. Due to the physiologic parameters used in the Revised Trauma Score, patients who do not have a recorded Glasgow Coma Scale (GCS) will not have a TRISS value calculated. Fiscal Year: April 1, 2003 - March 31, 2004

z Score W Score Sample Size Adult Blunt 2.94 2.6 585 Adult Penetrating 0.93 - 24 Paediatric 0.23 - 3 Total Subset 3.06 2.62 612

Data: 1995 – 2004

z Score W Score Sample Size

Adult Blunt 5.54 1.95 3833 Adult Penetrating 1.84 - 166 Paediatric 0.61 - 13 Total Subset 5.80 1.99 4012

For 1995 - 2004, there were 1.99 more survivors per 100 than would have been expected from the major trauma outcome study. The Alberta Trauma Registry at FMC has 5892 patient records in total. 68% (4012 patients) were eligible for z and W score while 32% (1880) were not eligible for the following reasons: not blunt or penetrating injury, missing data such as respiratory rate, systolic blood pressure, GCS, (components of the revised trauma score).

Outcome and Probability of Survival

With a probability of survival > 20%, did the patient die at the FMC trauma centre?

Indicator Yes No

2003/2004, n = 610 19 591

2002/2003, n = 536 17 519

2001/2002, n = 515 11 504

2 3.13

98 97 96.9

2001/2002 2002/2003 2003/2004

%Yes %No

n = all patients with probability of survival valued and probability of survival > 20%.

Alberta Children’s Hospital Performance Indicators Submitted by: Ms. Maria Vivas, Data Analyst Regional Trauma Services Calgary Health Region


Performance Indicator - ACH 64

Alberta Children's Hospital PERFORMANCE INDICATORS

As part of the Regional Trauma Services quality improvement process, several 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 FMC and the ACH as site specific performance indicators. The following is a summary of these indicators for the ACH for patients who meet the inclusion criteria for the Alberta Trauma Registry (patients with an ISS > 12, and who are admitted to the hospital or die in ED at the ACH). All cases flagged by a performance indicator or audit filter are reviewed by the ACH Trauma Audit Committee to determine appropriateness of care. *Each performance indicator number is based on the specific determinant of the indicator within the total of 97 patients. *If the ACH Trauma Audit Committee identifies cases where there were questions, the committee generates letters to follow up on those cases.

PRE-HOSPITAL PERFORMANCE INDICATORS

GCS < 8 at Scene - Mechanical Airway Did the patient have a GCS < 8 at the scene and have mechanical airway as an intervention at the injury scene?

Indicator Yes No

2003/2004, n = 12 3 9 2002/2003, n = 19 8 11 2001/2002, n = 14 7 7

42.150.025.0

50.0 57.975.0

2001/2002 2002/2003 2003/2004

%Yes %No

n = all patients with 1st recorded GCS ≤ 8 at the scene.

Transport Team

The ACH Transport Team is a neonatal/paediatric transport service that can be mobilised for trauma transports in and out of the region. The team consists of one physician (ICU or ED), a Respiratory Therapist and an ACH ICU nurse. Mobilisation is achieved through the ICU. The ACH Transport Team responds to the referring hospital and never to the scene (see the report included in the Pre-hospital Annual Report).

ACH Transport Team Utilization Was the patient transported by the ACH Transport Team? All patients were transferred from a primary or secondary hospital. The ACH Audit Committee reviews all eligible patients not transferred by the transport team, to determine if this service would have benefited them. Follow-up includes strategies to educate and raise awareness of this valuable service and to provide instruction on how to access it. Use of the service is encouraged. Indicator Yes No 2003/2004, n = 47 7 40 2002/2003, n = 36 6 30 2001/2002, n = 43 10 33

16.723.3 14.9

76.7 83.3 85.1

2001/2002 2002/2003 2003/2004

%Yes %No



INTERHOSPITAL TRANSFER OUTSIDE CALGARY

Time Spent at Sending Hospital Outside Calgary Did the patient spend < 2 hours at the sending hospital outside of Calgary, prior to transfer to ACH trauma centre? This indicator is new and combines the primary and secondary hospitals into the “sending hospital”.

Indicator Yes No

2003/2004, n = 26 9 17

34.6

65.4

2003/2004

%Yes %No

n = all patients transferred from a sending hospital outside Calgary, with a known sending hospital LOS.

Known Injury Time to Trauma Centre Did the patient arrive at a trauma centre < 4 hours from the time of injury? Trauma Centre is defined as ACH, FMC, or Stollery Hospital in Edmonton.

Indicator Yes No

2003/2004, n = 65 45 20

2002/2003, n = 51 32 19

2001/2002, n = 29 7 22

62.7

24.1

69.2

75.9

37.3 30.8

2001/2002 2002/2003 2003/2004

%Yes %No

n = all patients transferred from a hospital outside Calgary with a known time of injury and known time of arrival.

RESUSCITATIVE PHASE

At ACH, activation of the trauma team is through ED at the discretion of the ED physician. All major trauma cases are reviewed through the ACH audit process. All cases where the trauma team was not activated are reviewed to determine if appropriate trauma care was delivered without the full trauma team present.

Major Trauma Team Activation 2003-2004

43

7

3

8

32

10

3 32


# of

Act

ivat

ions



ED LOS Did the patient have an ACH ED length of stay < 4 hours at the ACH trauma centre?

Indicator Yes No

2003/2004, n = 78 44 34

2002/2003, n = 76 46 30

2001/2002, n = 82 52 30

60.563.4 56.4

36.6 39.5 43.6

2001/2002 2002/2003 2003/2004

%Yes %No

n = all patients seen in ACH ED with a known ED LOS. Direct admissions are excluded.

GCS < 8 at ACH ED - Mechanical Airway Did the patient with a first recorded trauma centre GCS < 8 receive a mechanical airway as an intervention in the ACH ED?

Indicator Yes No

2003/2004, n = 3 3 0

2002/2003, n = 4 2 2

2001/2002, n = 6 6 0

50

100 100

50

2001/2002 2002/2003 2003/2004

%Yes %No

n = all patients with 1st recorded trauma centre GCS ≤ 8.

DEFINITIVE CARE

Admitting Physician Was the patient admitted to a surgeon or an intensivist at the ACH trauma centre? There was a 25% increase in the number of patients admitted to the surgeon or intensivist in 2003-2004. 16 patients were admitted to the hospital-based paediatricians.

Indicator Yes No

2003/2004, n = 96 80 16

2002/2003, n = 89 64 25

2001/2002, n = 96 80 16

71.983.3 83.3

16.7 28.1 16.7

2001/2002 2002/2003 2003/2004

%Yes %No

n = all patients admitted to ACH Trauma Centre. One ED death was excluded.



CT of the Head Did the patient with a GCS < 12 receive a CT of the head at a sending hospital or within 4 hours of arrival at the ACH trauma centre?

Indicator Yes No

2003/2004, n = 6 5 1

2002/2003, n = 7 6 1

2001/2002, n = 8 7 1

85.787.5 83.3

12.5 14.3 16.7

2001/2002 2002/2003 2003/2004

%Yes %No

n = all patients with a known ED GCS and a known time of CT head. Patients that arrive intubated to ACH are excluded.

Craniotomy If the patient had an epidural or subdural brain hematoma, was a craniotomy performed within 4 hours of arrival at ACH trauma centre?

Indicator Yes No

2003/2004, n = 4 4 0

2002/2003, n = 2 1 1

2001/2002, n = 2 0 2

50

100100

50

2001/2002 2002/2003 2003/2004

%Yes %No

n = all patients with epidural or subdural hematoma where operative management was the planned intervention.

Femur Fracture Did the patient have operative management of femur fracture within 24 hours of arrival at ACH trauma centre?

Indicator Yes No

2003/2004, n = 9 8 1

2002/2003, n = 6 5 1

2001/2002, n = 7 7 0

83.3100 88.9

16.7 11.1

2001/2002 2002/2003 2003/204

%Yes %No

n = all patients requiring operative management of femur fracture.



Open 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.

Indicator Yes No

2003/2004, n = 4 4 0

2002/2003, n = 4 4 0

Not monitored prior to 2002/2003.

100100

2002/2003 2003/2004

%Yes %No

n = all patients requiring operative management of open fracture where grade of fracture is known.

Major Facial Fractures Did the patient with a facial fracture go to the operating room at ACH trauma centre within 7 days of injury?

Indicator Yes No

2003/2004, n = 3 3 0

2002/2003, n = 2 2 0

2001/2002, n = 2 2 0

2001/2002 2002/2003 2003/2004

%Yes %No

n = all patients requiring operative management of major facial fractures.

Unplanned Return to OR Did the patient have an unplanned return to the operating room at the ACH trauma centre?

Indicator Yes No

2003/2004, n = 31 0 31

2002/2003, n = 23 0 23

2001/2002, n = 24 0 24

100 100 100

2001/2002 2002/2003 2003/2004

%Yes %No

n = all patients with at least one operating room visit.



Delayed Diagnosis/Missed Injury Did the patient have a delayed diagnosis or missed injury at the ACH trauma centre?

Indicator Yes No

2003/2004, n = 96 2 94

2002/2003, n = 89 3 86

2001/2002, n = 96 1 95

3.41 2.1

99 96.6 97.9

2001/2002 2002/2003 2003/2004

%Yes %No


Missed C-spine Injury Did the patient have a missed c-spine injury with spinal precautions removed at the ACH trauma centre?

Indicator Yes No

2003/2004, n = 96 0 96

2002/2003, n = 89 0 89

2001/2002, n = 96 0 96

100 100 100

2001/2002 2002/2003 2003/2004

%Yes %No


Unplanned ICU Admission Did the patient have an unplanned admission to ICU at the ACH trauma centre?

Indicator Yes No

2003/2004, n = 96 1 95

2002/2003, n = 89 0 89

2001/2002, n = 96 0 96

1.04

100 100 98.96

2001/2002 2002/2003 2003/2004

%Yes %No




Unplanned ICU Readmission Did the patient have an unplanned readmission to ICU at the ACH trauma centre? There was one readmission to the ICU however, it was planned.

Indicator Yes No

2003/2004, n = 52 0 52

2002/2003, n = 36 0 36

2001/2002, n = 49 0 49

100 100 100

2001/2002 2002/2003 2003/2004

%Yes %No

n = all patients with at least one ICU admission.

OUTCOMES

Death During Transport Was the patient declared dead on arrival to the ACH trauma centre?

Indicator Yes No

2003/2004, n = 97 0 97

2002/2003, n = 93 0 93

2001/2002, n = 98 0 98

100 100 100

2001/2002 2002/2003 2003/2004

%Yes %No

n = all trauma patients arriving in ACH Trauma Centre.

Death During First 24 Hours Did the patient die within the first 24 hours of admission to the ACH trauma centre?

Indicator Yes No

2003/2004, n = 7 5 2

2002/2003, n = 9 5 4

2001/2002, n = 11 7 4

55.663.6 71.4

36.4 44.428.6

2001/2002 2002/2003 2003/2004

%Yes %No

n = all patients who died.



Mortality Did the patient die?

Indicator Yes No

2003/2004, n = 97 7 90

2002/2003, n = 93 9 84

2001/2002, n = 98 11 87

9.711.2 7.2

88.8 90.3 92.8

2001/2002 2002/2003 2003/2004

%Yes %No

n = all trauma patients arriving at ACH trauma centre.



Trauma Score Injury Severity Score (TRISS) Methodology TRISS methodology uses logistic regression to predict survival based on the Revised Trauma Score (RTS), injury severity score (ISS), mechanism of injury (blunt vs. penetrating) and patient age. Unexpected deaths are trauma patients with a predicted probability of survival of 0.5 or more that die and unexpected survivors are trauma patients with a predicted probability of survival of 0.49 or less that survive. TRISS ‘z’ statistic measures the statistical significance of the difference between the actual number of survivors among a set of patients and the number of survivors expected from outcome norms. W measures the clinical significance of the differences between the actual and unexpected survivors. W is the number of survivors more than would be expected from the outcome norms per 100 patients treated. W can be calculated if the z score is greater than 1.96. Due to the physiologic parameters used in the Revised Trauma Score, patients who do not have a recorded Glasgow Coma Scale (GCS) will not have a TRISS value calculated.

ACH z and W Score (“Adult” indicates > 15 years of age)

Fiscal Year: April 1, 2003 - March 31, 2004

z Score W Score Sample Size Adult Blunt 0.39 - 12 Adult Penetrating 0.13 - 1 Paediatric 0.32 - 54 Total Subset 0.44 67

The z score is not statistically significant due to low patient numbers; therefore, the W score cannot be calculated. Data: 1995 – 2004

z Score W Score Sample Size Adult Blunt 0.96 - 46 Adult Penetrating 0.45 - 2 Paediatric 3.63 3.08 471 Total Subset 3.78 2.99 519

For 1995 - 2004, there were 2.99 more survivors per 100 than would have been expected from the major trauma outcome study. The Alberta Trauma Registry at ACH has 828 patient records in total. 63% (519 patients) were eligible for z and W score while 37% (309 patients) were not eligible for the following reasons: not blunt or penetrating injury, missing data such as respiratory rate, systolic blood pressure, GCS, (components of the revised trauma score).

Outcome and Probability of Survival Did the patient with a probability of survival > 20% die at the ACH trauma centre?

Indicator Yes No

2003/2004, n = 67 1 66

2002/2003, n =62 0 62

2001/2002, n=64 2 62

3.1 1.5

96.9 100 98.5

2001/2002 2002/2003 2003/2004

%Yes %No

n = all patients with probability of survival valued and probability of survival > 20%.

Pre-hospital Annual Report 2003 - 2004

`Note: Reports were prepared and submitted by various partners/groups within the Pre-hospital system.


Pre-hospital Report 74

PRE-HOSPITAL ANNUAL REPORT (2003-2004)

1. PROVINCIAL COORDINATION Emergency Health Services, Alberta Health & Wellness Southern Alberta has a comprehensive network of pre-hospital providers that contribute to the provision of trauma care in this province. The Calgary Health Region Regional Trauma Services based at the Foothills Medical Centre is the receiving facility for all adult major traumas in Southern Alberta. The Alberta Children’s Hospital receives the paediatric population (<15 years of age). The City of Calgary itself possesses a highly evolved Advanced Life Support (ALS) Ambulance Service that services the city itself. They work in conjunction with Calgary’s Fire Service that provides first responder and co- responder capability to the city. In addition to Calgary, there are a large number of ambulance services providing care in the smaller communities in southern Alberta, all of which may feed into the Regional Trauma Network. These services range from low volume volunteer Emergency Medical Responder (EMR) services (e.g. Foremost) to the larger mid to high volume ALS ambulance services (e.g. Medicine Hat, Lethbridge, and Red Deer). Each of the individual services in the province is required to have a medical director to oversee the care given by the providers working under their medical license. The degree of involvement of the individual medical directors is very diverse. It can range from services that employ medical directors in almost a full time capacity to those smaller services, which may only have medical direction for a few hours each month. It should be noted that the Province of Alberta has recently begun an initiative to educate medical directors from smaller services in order to improve overall medical direction in this province. Medical directors are responsible for overseeing Quality Management/Continuous Quality Improvement (QM/CQI) of the providers in their service. This would include Patient Care Report (PCR) reviews, field performance audits (“ride-alongs”) and dispatch audits. Audit criteria are set by the individual medical director and can vary significantly. Some services audit all of the PCRs while high volume services may only audit a representative proportion. Most services will retrospectively audit all major traumas. Medical directors would also be responsible for ensuring training and continuing education guidelines for all of their services being met. This would include ensuring providers are current in Basic Trauma Life Support (BTLS) or equivalent trauma in-servicing. All of the larger receiving hospitals in Southern Alberta (Calgary, Lethbridge, Red Deer, and Medicine Hat) have base station physicians capable of providing ‘on-line’ medical control to Emergency Medical Services (EMS) providers prior to and during transport of critically injured patients to their facilities. A 9-1-1-phone linkage services the majority of this province. This puts citizens in contact with dispatch personnel who can then deploy appropriate resources. The majority of Southern Alberta has excellent cellular coverage but due to the large geographic area, much of which is sparsely populated, there still exists some challenges to communication between citizens, ambulance personnel and receiving facilities.

The Province of Alberta coordinates all interfacility air ambulance transports within the province through the Provincial Flight Coordination Centre (PFCC) in Edmonton. They perform the same role for air transports in Eastern BC and, on occasion, western Saskatchewan should patients from these provinces have a bed in Alberta. Central coordination of ground ambulance transfers of trauma patients does not yet exist. This transport is usually coordinated through direct communication between the sending and receiving facilities.



A typical inter-facility transport of a trauma patient in this province would evolve as follows: ● Trauma patient arrives in sending facility by private vehicle or EMS. ● Decision made to transport patient to regional trauma facility. ● Direct sending physician-to receiving -physician consultation ensues and a decision is made on mode of

transport (air vs. ground, rotary vs. fixed-wing) and level of care required during transport. ● At this time, typically a referral emergency physician (REP) from the Calgary Health Region is involved in

the transport decision as well as the PFCC (if air transport is required) ● If air transport required the PFCC coordinates the flight based on patients needs and resources (aircraft)

available. ● If ground transport is deemed appropriate the sending, receiving and REP will ensure that the patients

needs are met and appropriate transport attendants are available. For trauma this will always consist of at least an ALS paramedic crew. Typically Advanced Life Support (ALS) paramedics provide in-transit life support. Nurses, respiratory technicians or physicians, if deemed necessary, may supplement the transport crews. STARS most often deploys a paramedic/nurse team.

Prepared and submitted by: Hal B. Canham MD, CCFP(EM) Tyler James Medical Director Manager Provincial Air Ambulance Program Air Ambulance and Emergency Planning Emergency Medical Services Alberta Health and Wellness Alberta Health and Wellness



2. CITY OF CALGARY EMERGENCY MEDICAL SERVICES (EMS)

Calgary EMS is a fully ALS ambulance service. Every ambulance is staffed with two paramedics or one paramedic and one EMT-A. Every Paramedic Response Unit (PRU) is staffed with one paramedic. This fully ALS service provides citizens with the highest quality out of hospital medical care that can be attained in Canada.

The following lists the volume of Emergency unit responses by year and the percentage increase from year to year.

2001 74,172 responses (+7.1%) 2002 80,465 responses (+6.3%) 2003 87,505 responses (+8.8%) 2004 92,439 responses (+ > 5 %)

To provide this service EMS has the following units in operation:

Active Ambulances: 39 Spare Ambulances: 15 Support Units: 19 TOTAL 73

• 23 Advanced Life Support (ALS) units are on duty 24-hours per day. (19 ambulances and 4 Paramedic

Response Units). • There are 16 additional peak-time ALS ambulances on duty during the day, when call volumes are

highest. • An ALS air medical crew is on duty 24-hours per day to fulfil our contract with Alberta Health & Wellness

Calgary EMS’ response time goal is to reach life threatening emergencies in 8 minutes or less 90% of the time. Currently we are achieving that response goal 77.53% of the time. In 2003, Delta (life threatening) responses had the following response times:

Mean – 6.6 minutes Median – 5.8 minutes

Response time grew in 2004 by 4 seconds over the previous year to 6 minutes and 56 seconds with an ultimate goal to move closer to six minutes. Medically trained staff at the EMS Communication Centre receives requests for service from a variety of sources, including the general public, other City of Calgary departments (Police, Fire, Transit, etc), the Provincial Flight Coordination Centre, and the Calgary Health Region. Requests are received from 911 phone lines at Rotary Park, non-emergency phone lines, speciality direct phone lines, and directly over the radio system. Calls are categorized, evaluated, and prioritized according to a Medical Priority Dispatch System (MPDS). Developed in the USA, the MPDS is used for emergency medical dispatch in more than 20 countries, and in many centres in Canada. The proven success of the system has resulted in it being accepted as the international standard of care and practice. Based on the information provided by the caller, the proper agency and level of response that is required in each situation is determined. The Communication Centre’s staff compliance with well-established evidence-based response protocols is monitored on an ongoing basis to ensure the highest possible standard of service. Overall quality assurance compliance in the Communications Centre is consistently well above the 90% benchmark. While calls are being evaluated, the EMS dispatcher works to maximize the use of EMS resources from minute-to-minute, coordinating and deploying units to facilitate timely response to emergency and non-emergency events. The delivery of pre-hospital care at The City of Calgary EMS is informed and supported by the medical direction of a licensed emergency physician. Dedicated to the pursuit of high quality evidence-based practice, the Medical Director provides medical control to the practice of our licensed staff, in keeping with legislation



under the Health Discipline’s Act. This means that the Medical Director issues orders for care in the field, within the registered staff member’s scope of practice, defining patient management through protocols (medical control guidelines), verbal or written orders, and medical audits. In addition, the Medical Director collaborates with emergency physicians in the hospital community through a Medical Advisory Board, seeking their input and feedback on trends, changes and, the results of pre-hospital care. Also, the Medical Director establishes linkages between EMS and other community services, such as The City of Calgary Fire Department and the Calgary Health Region.

Other supports and linkages include: • First Response – Calgary EMS is supported in First Response by the Calgary Fire Department. • Fixed Wing Air Medical is provided by Calgary EMS. • Rotary Service is provided by Shock Trauma Air Rescue Society (STARS). • Calgary Health Region (CHR) provides most of the inter-facility patient transport service (CHPTS). EMS

provides inter-facility transport on behalf of the CHR as requested, usually when transport volumes exceed the CHR’s immediate capacity.

• Neo-natal cases are transported with a Paediatric Transport team from the Alberta Children’s Hospital. • Physicians occasionally attend on ALS referral centre flights. Accomplishments The City of Calgary EMS has a number of accomplishments that contribute to the enhancing the management of trauma patients in the pre-hospital environment. They include:

(1) The Revision and Development of Medical Control Guidelines Work is underway to revise the Medical Control Guidelines. In November 2004 the revised Medical Control Guidelines (MCGs) for the City of Calgary Emergency Medical Services Department will be completed with minor changes and distributed to paramedics.

(2) A New Spinal Injury Algorithm & Participation in the Canadian C-Spine Rule Study Work continues to provide data for the Canadian C-Spine Rule Study and anticipate our contribution will be complete by years end.

Stephen Donaldson, EMT-P; Ian G. Stiell, MD, MSc; George A. Well, PhD; Lisa P. Nesbitt, RRCP; Andrew Anton MD et al. A Pre-hospital Study to Prospectively Validate the Canadian C-Spine Rule Study for Alert and Stable Trauma Patients

Reference Document: Stiell IG, Wells GA, Vandemheen K, Clement C, Lesiuk H, De Mario VJ et al. The Canadian Cervical Spine Radiography Rule for alert and stable trauma patients. JAMA 2001; 286(15): 1841 – 1848

(3) The Introduction of Rapid Sequence Intubation (RSI) and LMA Rapid Sequence Intubation (RSI) was introduced into paramedic care in May 2000 with LMA being added to the ambulances in 2002. The use of RSI and the LMA’s seems to have contributed to a profound decrease in surgical cricothyrotomies.

EMS Surgical Cricothyrotomies

11

8

20

10

02 2

05

10152025

1998 1999 2000 2001 2002 2003 2004



(4) Trauma Statistics Upon completion of each patient encounter, paramedics complete a Patient Care Report (PCR). One task in completing the PCR is assigning an appropriate Patient Diagnostic Code (PDC). The PDC is based on a list of conditions/injuries set out by Alberta Health & Wellness.

Listed below are the PDCs for major trauma patients for 2002, 2003, 2004. Major Trauma PHI ≥ 4

Major Trauma 2004 2003 2002

00 Trauma Arrest Attempted * 45 28 16 01 Paediatric ≤ 14 years 103 83 41 02 MVC 300 293 267 03 MBC 37 41 43 04 Struck by Vehicle 91 80 74 05 Gunshot 7 8 9 06 Stabbing 79 70 95 07 Fall 163 176 127 08 Assault/Blunt Trauma 62 41 75 09 Other 23 23 35 TOTAL 501 522 782

* Resuscitation of the patient with trauma arrest was attempted. Quality Improvement Activities included: • Documentation Audits • Operational Audits • Focused Audits • Response Monitoring • Process Evaluation • Quality Teams (Self Assessment Process) • Performance Indicator Monitoring Prepared and submitted by: Heather Klein-Swormink, MBA, BscN, RN Dwayne Clayden M.E.M., EMT-P Quality Assurance Strategist Assistant to the medical Director Emergency Medical Services



3. FIXED WING TRANSPORTS

Southern Alberta is serviced under a provincial air ambulance system governed by the Alberta Health and Wellness Emergency Health Services branch. The province has three fixed-wing aircraft in the south, one stationed in Calgary and two in Medicine Hat. They also have a rotary wing aircraft (i.e. STARS) located in Calgary. The province also has the capability of deploying aircraft from bases in the northern part of the province should the need arise. Typically STARS would be the only aircraft deployed on trauma scene calls in and around Calgary. They might be involved in inter-facility transports of trauma patients up to a 225 km radius from Calgary. Fixed-wing inter-facility transport of trauma patients would typically occur outside this 225 km radius of Calgary, although depending on resource availability, they may also respond within this radius. Alberta Health and Wellness policy dictates that for high priority, critically injured patients the rotary aircraft must be ‘skids up’ in 15 minutes or less and the fixed-wing aircraft must be ‘wheels up’ in 30 minutes or less. An additional 15 minutes is allotted should a physician be required on a flight. Alberta Health and Wellness has developed a comprehensive ‘Chart of Call’ that lists communities in Alberta, B.C., and Saskatchewan that may make use of our aircraft. This Chart of Call provides the PFCC with information on: ‘time to patient’, ‘time to tertiary care’ and ‘out of hospital times’ for patients in the different communities we serve. We are then able to deploy our resources accordingly. Medical control of air transport is complex. The individual air ambulance carriers are staffed by ambulance personnel from the service of origin and, as such, are under the off-line (indirect) medical control of the medical director of that service (Medicine Hat Ambulance Service, City of Calgary EMS, STARS). On-line (direct) medical control can be provided by the on-call Referral Emergency Physician (REP), discussed above. All of the above services have knowledgeable, experienced medical directors who have comprehensive Quality Management (QM) programs relative to their air ambulance activities. In addition, Alberta Health and Wellness contracts two medical directors who are on call 24/7 to provide medical direction to the flight coordinators at the PFCC. They aid in making decisions on deployment of the resources available to the air ambulance program. They also are present to insure the Policies and Procedures of the Flight Coordination Centre are adhered to. Prepared and submitted by: Hal B. Canham MD, CCFP(EM) Tyler James, Manager Medical Director Air Ambulance and Emergency Planning Emergency Medical Services Alberta Health and Wellness Alberta Health and Wellness



4. SHOCK TRAUMA AIR RESCUE SOCIETY (STARS)

The Alberta Shock Trauma Air Rescue Society (STARS) provides critical care level rotary wing transport for trauma patients throughout Alberta and south eastern BC. Two pilots, a paramedic and a nurse are ready 24 hours a day, seven days a week at both bases to provide care and transport to critically ill and injured patients. A referral emergency physician accompanies patients on the helicopter on about 50% of the missions and is available and provides online medical supervision and control throughout all missions. STARS is fully Accredited through the Commission on Accreditation of Medical Transport Systems (CAMTS). The STARS Emergency Link Centre (ELC) is an advanced 24-hour communications centre providing one-call access to a variety of resources. Around the province, the ELC plays several important roles. These roles range from receiving the first call for help from an organization or individual, to being called by a partner in the “Chain of Survival” for assistance with an emergency. In all cases, the ELC's primary job is to connect all of the emergency and medical services into a single conversation to determine the most effective medical response for the patient and the particular situation. This includes the immediate coordination of medical advice, medical referral and transportation as required. This "One Call Does it All" is being used by the Calgary Health Region's Rapid Access Line in Calgary providing physicians from rural communities with quick access to patient referral and specialist advice in affiliation with the ELC. The STARS Quality Management Program (medical component) includes review of patient care records for appropriateness of patient care and documentation including secondary screens of any patient transport which involves airway management, blood administration, high risk obstetrics, paediatric patients, patients who arrest while in the care of STARS, or does not meet the utilization review criteria. All transports are monitored for adherence to response time thresholds. Any event which meets the criteria in the risk analysis template for moderate to high risk events undergoes a Sentinel Event Review. The STARS Human Patient Simulator (HPS) Program is the first mobile program of its kind in North America. The HPS is a dynamic, interactive, computerized mannequin. It is used for very specific, guided, intensive contact and analysis of Advance Medical Care (AMC) critical thinking skills by the medical director. The HPS mannequin simulates complex medical and traumatic problems over and over again, offering medical personnel an opportunity to test and practice their reactions and skills leading to a high degree of familiarity and confidence. In addition, patient care scenarios in our aircraft mock-up enhance the experience and better prepare our AMC for actual air medical transport events. STARS transports trauma patients based on its Utilization Criteria. All major trauma patients are taken to the Foothills Hospital Medical Centre or the Alberta Children’s Hospital depending on the age of the patient. STARS owns 4 BK-117 helicopters. One primary response aircraft is based in both Calgary and Edmonton with two back up helicopters available for maintenance periods. Response times are as follows: ● Scene Response - 8 minutes from dispatch to launch for scene calls (up to 12 minutes if extra fuel or

supplies are required for longer scene response). ● Interfacility Transport - 10 minutes from dispatch to launch (up to 15 minutes for weather checks, fuelling

or addition of supplies). ● Interfacility Transport with Physician – 20 minutes from dispatch to launch. Medical Control is provided by the Referral Emergency Physicians in each respective base. Prepared and submitted by:

Heather McLellan RN BN Quality Improvement and educational Development Coordinator STARS



5. The Paediatric Transport Team

In addition to STARS and Air Ambulance medical evacuation transport, the Alberta Children’s Hospital offers a specialized Paediatric Transport Team service, which transports critically ill or injured children from referring centers. A direct trauma line is available to access helicopter/fixed wing transports by the ACH transport team. All paediatric transports have Paediatric Intensive Care Unit (PICU) physicians attending medical control together with STARS MD for helicopter transports. A specialized paediatric transport team provides inter-hospital transports with PICU medical control. The PICU attending will also liaison with STARS for triage decisions and joint transport/medical control of scene calls. The ACH Transport Team does not respond directly to scene calls. In the past we have not had consistent medical control but now through Link Center communications, medical control is achieved via the PICU attending on call. Review and feedback to stakeholders is conducted if this does not occur. We are presently developing a specialized paediatric team of RN/RTs complement to address lack of availability of paediatric team mobilization due to lack of MD coverage. This new program should be in place within the next 2 years. Ongoing review and quality assurance of all paediatric transports occurs with monthly transport meetings to address transport issues.

Prepared and submitted by: Dr. Catherine Ross Paediatric Intensivist Alberta Children’s Hospital

Regional Department of Emergency Medicine Report 2003-2004 Submitted by: Maureen McNaul RN MBA Service Planning Coordinator Regional Emergency Services Calgary Health Region


ED Report 83

Emergency Services Vision, Purpose and Values Vision Statement The Calgary Health Region’s Emergency Department shall provide excellent, timely patient care utilizing state of the art technology and continuous quality improvement techniques. The Emergency Department Team will strive to earn the trust and respect of patients and their families, the medical community and our co-workers while maintaining the focus on our team approach to patient centred care. Purpose of Emergency Services The Emergency Department Team provides 24-hour access to a full spectrum of care for patients of all ages for any perceived emergency health need, from life threatening to minor conditions. Value Statement Regional Department of Emergency Medicine and Emergency Services Respect: Non-judgmental acknowledgement of the unique contributions, dignity, autonomy and worth of

individuals Caring: Sensitivity to and support for the well being of staff, patients and families Accountability: Assuming responsibility for ones actions and decisions within ones scope of responsibility Teamwork: A commitment to work together towards our common goals through effective communication,

collaboration and tolerance of variation Growth: Personal and organization commitment to progressive development and life long learning Excellence: A commitment to strive for the highest quality of patient care and personal relationships Fairness: The opportunity for open and non-judgmental communication of differing view points on any

issue Decisions and the decision-making process will support the Mission, Vision and Values of the Emergency Department team. A patient centred approach will be taken when making decisions. By taking a patient centred approach, the patient and family is considered a partner in the decision making process. Goal Statement Patients & Clients: Continuously improve public confidence in Calgary Health Region Emergency

Departments with patient centred care. Innovative Service Delivery: Improve access to quality Emergency Health Services. Financial Accountability: Achieve Financial Health. People & Partners: Employer of choice and trusted partner with other departments and external

agencies.


ED Report 84

Overview The Calgary Health Region’s Emergency Departments play an integral role in providing emergency care to residents of Calgary, Southern Alberta, Southeastern British Columbia, Southwestern Saskatchewan and out of province visitors. A population of nearly 1.5 million is served. The Emergency Departments (ED’s) provide a unique service to the community and to the hospitals, caring for a large number of patients with diverse and complex health concerns. A full scope of service is provided and ranges from resuscitation to the treatment of patients with non-urgent conditions. The ED’s play a key role in partnering with Trauma Services to effectively manage the population of trauma patients. For many trauma patients, the Emergency Department is their first major point of entry to the health care continuum. Please refer to Appendix I for a description of Emergency Services Values, Vision and Purpose. Emergency Services is responsible for the operations of the three adult Emergency Departments within the Calgary Health Region including the Foothills Medical Centre (FMC), Peter Lougheed Centre (PLC) and the Rockyview General Hospital (RGH). There are over 200,000 emergency visits each year among these three sites. While the Emergency Department at the Alberta Children’s Hospital (ACH) is administered under the Child Health Portfolio, there is a close working relationship with the Regional Department of Emergency Medicine (RDEM). ACH Emergency receives approximately 45,000 patient visits each year. The FMC and ACH are the designated adult and paediatric trauma centres for Southern Alberta respectively, but the PLC and RGH also receive and treat trauma patients as well. Perceived personal patient need, physician or other health care provider referral and ambulance protocols dictate access to any one of the EDs. The EDs provide 24-hour access to health care for individuals of all ages who have unscheduled health care needs. In order to manage this diverse patient population, all Calgary Health Region ED’s use the nationally recognized, standardized triage-scoring system known as the Canadian Triage Acuity Scale (CTAS). Experienced and highly trained ED Nurses assign each patient with a priority level based on how they present upon arrival to the ED. The CTAS ratings include 1 (resuscitation), 2 (emergent), 3 (urgent), 4 (semi-urgent) and 5 (non-urgent). It is important to note that CTAS score is reflective of how the patient presents upon arrival and that their condition may improve or worsen over the course of their ED visit. The following information was excerpted from “Implementation Guidelines for The Canadian Emergency Department Triage and Acuity Scale (CTAS)” which is endorsed by the Canadian Association of Emergency Physicians (CAEP), the National Emergency Nurses Affiliation of Canada (NENA), and L’association des médecins d’urgence du Quebec (AMQU). Please note that we have only presented CTAS Level classification information as it applies to trauma patients. There is a wide range of other types of patients that fall within each CTAS category as well. Trauma patients presenting to the ED are classified as follows: CTAS Level 1 Resuscitation • Major trauma: severe injury of any single body system or multiple system injury, Head injury with Glasgow

Coma Scale < 10, severe burns, chest/abdominal injury with any or all of: altered mental state, hypotension, tachycardia, severe pain, respiratory signs or symptoms

CTAS Level 2 Emergent • Head injury: This problem appears in several triage levels. The more severe or high-risk patients require a

rapid MD assessment, to determine the requirements for airway protection/CT scanning or neurosurgical intervention. These patients usually have an altered mental state (Glasgow Coma Scale ≤ 13). Severe headache, loss of consciousness, confusion, neck symptoms and nausea or vomiting can be expected. Details regarding the time of impact, mechanism of injury onset and severity of symptoms and changes over time are very important.

• Severe trauma: These patients may have high-risk mechanisms and severe single system symptoms or multiple system involvement with less severe signs and symptoms in each. Generally the physical assessment of these patients should reveal normal or nearly normal vital signs (Abnormal VS are CTAS level 1). These patients may have moderate to severe pain and normal mental status (or meet the criteria outlined for level II head injuries).


ED Report 85

CTAS Level 3 Urgent • Head injury: these patients may have had a high-risk mechanism. They should be alert (GCS 15) moderate

pain (<8/10) and nausea or vomiting. Should be changed to level 2 if deteriorating or just appears unwell. • Moderate trauma: Patients with fractures or dislocations or sprains with severe pain (8-10/10). Nursing

intervention with splinting/analgesics making it reasonable to have some delay in time to physician assessment/intervention. Dislocations should be reduced one hour, so physician assessment should occur in ≤ 30 minutes. Patients are “stable” (normal or near normal vital signs).

CTAS Level 4 Semi-Urgent • Head Injury: Minor head injury, alert (GCS 15), no vomiting or neck symptoms and normal vital signs. May

require brief period of observation, depending on time of injury in relation to ED visit. If time interval from accident > 4-6 hours and has remained free of symptoms, a neuro check and head routine sheet may be all that is necessary. The age of the patient and characteristics of the care provider/support at home may also influence the disposition decision or observation period.

• Minor trauma: minor fractures, sprains, contusions, abrasions, and lacerations, requiring investigation or intervention. Normal vital signs, moderate pain (4-7/10).

CTAS Level 5 Non-Urgent • Minor trauma: contusions, abrasions, minor lacerations (not requiring closure by any means), overuse

syndromes (tendonitis), and sprains. Nursing interventions, splinting, cleansing, immunization status, minor analgesics are all expectations of patients in this category.

Trauma Patient Quality Improvement Practices A series of treatment protocols, standards and guidelines have been developed for managing trauma patients in the ED in close collaboration with the Regional Trauma Services team. Quality Improvement processes are established to monitor and evaluate compliance. The RDEM participates actively on the Calgary Health Region Trauma Committee, which facilitates open communication, collaboration and problem solving. Protocols, standards and policies related to managing trauma patients are reviewed annually and on an ad hoc basis based on current research evidence. The following standards, guidelines, and protocols are monitored by Trauma Services:

• Trauma Team activation based on activation criteria • Trauma Team Leader (TTL) response time </= 20 minutes • Compliance with Spinal Clearance Protocol based on the Canadian C-spine study • Documentation of vital signs q30 min for all trauma patients in the ED • Documentation of sequential neurological vital signs as appropriate • ED length of stay >/= 4 hours • Admission of major trauma patients to a surgeon or intensivist • Use of mechanical airway in ED for patients with a first recorded GCS </= 8 • Joint dislocations reduced less than 1 hour of arrival • Time to CT of the head for patients with a GCS < 13 (standard is < 4 hours) • Time to craniotomy for patients with epidural or subdural brain hematoma • Time to laparotomy for patients with suspected intra-abdominal injury

Note: Regional Trauma Services collects data in the Alberta Trauma Registry on all major trauma patients with an ISS >/= 12 who are admitted to hospital or die in the Emergency Department. ISS is an anatomical scoring tool indicating severity of injury. In addition to the above, Emergency Nurse Clinicians have been working closely with Trauma Services to understand the importance of thorough documentation and the subsequent impact on Trauma Registry data. It is also Emergency Department practice for any unusual matters to be brought to the attention of the Trauma Clinical Nurse Specialist.


ED Report 86

The Emergency Department actively participates in a wide range of Quality Improvement projects, most of which will positively impact the care of all emergency patients, including those who are trauma victims. Some examples include:

• Enhanced triage staffing at all sites and implementation of triage guidelines regarding reassessment of waiting room patients according to CTAS level. Renovations/upgrades to triage areas at FMC and PLC were also completed to better facilitate triage activities.

• Tracking of consultation request time and decision to admit (inpatient bed request) time in the Regional Emergency Department Information System (REDIS).

• Credentialing of ED physicians under the Canadian Association for Emergency Physicians (CAEP) to perform FAST (Focused Assessment with Sonography for Trauma) ultrasound in the department for conditions including pericardial tamponade, intrauterine pregnancy, abdominal aortic aneurysm, abdominal trauma and cardiac standstill. FAST is an extension of the clinical assessment and most helpful in trauma patients in shock.

Conclusion The volume of Emergency Department patients has been stable over the past several years for the Region, until fiscal 2003/04 when volumes increased by 3%. This increase was driven by growth of 8% at the PLC and 4% at ACH. Volume at the FMC has shown a gradual decrease and the RGH has remained stable. It is important to note that at adult sites, the proportion of older patients (40 and over, and especially in the 65+ category) is increasing. In addition, there has been an increase in CTAS Level 2 and 3 patients and a decrease in CTAS Level 4 and 5 patients which has stabilized over the last year. As a result, the typical ED patient is older, has greater presenting acuity and thus requires more extensive and complex assessment, diagnostic testing and treatment. All of these pressures, combined with higher patient volumes contribute to longer wait times and increased overall length of stay in the ED for all types of patients, including major trauma patients. Emergency Department Visit Data


ED Report 87

The standard for length of stay (LOS) for trauma patients in Emergency is ≤ 4 hours. 37.5% of the major trauma patients at FMC had an ED LOS ≤ 4 hours in 2003-2004 compared to 43.6% in 2002-2003. At ACH, 56.4% of the major trauma patients had an ED LOS ≤ 4 hours in 2003-2004 compared to 60.5% in 2002-2003.

P.A.R.T.Y. PROGRAM (Prevent Alcohol Related Trauma in Youth) 2003-2004 Submitted by: Lynda Vowell, RN BN P.A.R.T.Y. Coordinator Emergency Services Calgary Health Region


P.A.R.T.Y. Report 89

P.A.R.T.Y. Program Mission Statement To promote injury prevention through reality education, enabling youth to recognize risk and make informed choices about activities and behaviours. Goals and Objectives 1. Reduce the incidence of risk related trauma in youth.

1.1 Provide youth with positive alternatives and strategies to encourage smart choices. 1.2 Expose youth to potential psychosocial and physical impacts that result from traumatic injury,

using reality education. 1.3 Encourage youth to directly apply strategies learned at PARTY.

2. Empower youth to recognize risk and make informed, safe choices.

2.1 Identify potentially dangerous situations and behaviours through personal testimony, multi-media presentation and active participation.

3. Increase awareness of personal responsibility for choices.

3.1 Encourage youth to examine their attitudes, decisions and behaviours.

4. Increase knowledge of the impact of serious injury on quality of life for the individual and community.

4.1 Encourage youth to think about potential loss of independence, friends, self-esteem and control of their body, as a result of injury.

4.2 Identify the differences between injury recovery and permanent disability. 4.3 Expose youth to a variety of disability issues in the community.

5. Promote injury prevention initiatives.

5.1 Demonstrate PARTY Programs’ active participation in promotion of injury prevention initiatives at a local, provincial, national and international level.


P.A.R.T.Y. Report 90

2003-2004 ANNUAL REPORT This year completes the 15th season for P.A.R.T.Y Calgary. The program continues to be a highly respected, dynamic injury prevention/health promotion program targeting youth in Calgary and surrounding communities. The goal of the program is to inform and educate students about the perils of poor choices, risk-taking behaviours, and the consequences that may occur. Funding for this program is coordinated through the efforts of Calgary Health Trust, with Exxon Mobil Canada Limited as the lead corporate sponsor. In May we held a 15th anniversary celebration to recognize the community members contributing to our success, and our lead corporate sponsor, as well as Calgary Health Trust’s ongoing support. The success of this program is inherent on the diverse group of over one hundred dedicated individuals providing their time and talent to support the program. This group includes volunteers, various professional groups within the Calgary Health Region, as well as Calgary City Police, Calgary Emergency Medical Services, Calgary Fire Department, and a group of injury survivors who share their personal ‘stories’ with students on a regular basis. In the past year, the in-hospital presentations reached over 6000 grade nine students, with an additional 2000 attending outreach sessions. Waiting list numbers are consistent from year to year at 3500 students/year (does not include all grade nine students, only students from schools requesting access). This year saw the pilot project for our After the Party session (geared towards grade 12 students) at West Island College. We received excellent feedback from students, teachers and parents. We are targeting delivering the program to four local schools in the spring of 2005. A half time Assistant Coordinator position was added in the spring, a great enhancement to insure the program continues to meet the needs of our students.

Calgary Firefighters Burn Treatment Centre Report 2003-2004 Submitted by: Dr. Robert Lindsay, Deputy Director Ms. Christi Findlay, Data Analyst Foothills Medical Centre Calgary Health Region


Burn Report 92

BURN REPORT The Calgary Firefighters Burn Treatment Centre at the Foothills Medical Centre serves as the tertiary care facility for adults of Southern Alberta, Southwest Saskatchewan and Southeast British Columbia. Patients with other diagnoses such as frostbite and exfoliative disorders including toxic epidermal necrolysis may be managed in the Burn Unit. Those requiring ventilatory support are treated in the Intensive Care Unit at FMC. The new Calgary Firefighters Burn Treatment Centre will open on October 29th/2003. This centre will be an up-to-date physical facility for the comprehensive multi-disciplinary care of the acutely burned, non-ventilator dependent adult burn patient. A multidisciplinary team, whose members include plastic surgeons, nurses, physiotherapists, occupational therapist, nutritionists, and social workers, has been developed to care for the particular needs of this group of patients. The team meets weekly to discuss clinical issues, to address social concerns, to conduct educational sessions, and to engage in quality review procedures. Upon discharge, follow-up is arranged in outpatient clinics within the Rehabilitation Department at FMC, thus providing a degree of continuity of care during, the often lengthy, process of rehabilitation. The following is a summary of patients arriving at the Foothill Medical Centre with a diagnosis of burn, smoke inhalation or frostbite, comparing April 1, 2003 to March 31, 2004 with April 1, 2002 to March 31, 2003 and April 1, 2001 to March 31, 2002.

Admissions Hospital Days (Total)

42 45

73

1912 10

83

5761

2001/2002 2002/2003 2003/2004Male Female Total

998

1497 1536

2001/2002 2002/2003 2003/2004

2003/2004 male to female ratio: 7.3:1 2003/2004: median length of stay (LOS) = 10

average LOS = 18.5 range = 1 - 286 < 14 days: 38.6% (32/83)

Age Distribution

2

1311

14

8 8

3 2

10 911

13

7

13 3

9

17

26

8

31 2

17

< / = 20 21-30 31-40 41-50 51-60 61-70 71-80 > 81

2001/2002 2002/2003 2003/2004

2003/2004: median age = 40, average age = 39.7


Burn Report 93

Place of Occurrence Mechanism of Burn Injury

3429 27

1713

16

1 3 49

12

36

2001/2002 2002/2003 2003/2004

Home Work Motor Vehicle Other / Unknow n

19.3% of incidents producing thermal injury occur in the workplace.

4336

45

2 056 7 76 5 54 4

17

0 3 20 2 2

2001/2002 2002/2003 2003/2004

Thermal - Flame/Contact ChemicalScald/hot object ElectricalFrostbite/hypothermia Smoke InhalationUnknown

Total Body Surface Area Involved Injured Body Region

4449

57

7 5 64 1 12 2 3

2001/2002 2002/2003 2003/2004

< 20% 21-40% 41-60% 61-80%

Note: Excludes patients with no burn (smoke inhalation / hypothermia) or unknown total body surface area involved.

2922

44

5

2714

58

15

Head Trunk Extremity Lung(smoke

inhalation)2002/2003 2003/2004

Note: head includes face and neck; patient may have more than one body region injured; no data for 2001/2003

Intubation / Ventilation Operative Intervention

15 12 12

46 45

71

2001/2002 2002/2003 2003/2004

Yes No

22 274239

138

85

2001/2002 2002/2003 2003/2004

Patients Procedures

2003/2004: median # of operative procedures per patient=1 average # of operative procedures per patient=2 Note: altered definition of operative procedures may render comparison inaccurate


Burn Report 94

Mortality

2003/2004: mortality rate = 2.4% The number of admissions has remained relatively stable in recent years until 2003/2004 when there was a 45.6% increase in patient numbers. This trend appears to be continuing into the 2004/2005 year. The age distribution reflects the characteristic pattern of a high incidence within the age 21-50 year old male population. Contributory factors often include functional impairment, temporary or chronic substance abuse, physical or mental disability, neurological disease and old age. An increase in the number of burn cases in this past year may be caused by a variety of social and environmental factors including population growth, poverty without the necessary supportive environments, demands in the workplace with inadequate training and a growing substance/drug abuse culture. Coincident smoke inhalation injury and age have a major effect on morbidity and mortality in burn patients.

56 53

81

5 4 2

2001/2002 2002/2003 2003/2004


Tertiary Neurorehabilitation Program ♦ Traumatic Brain Injury Population ♦ Traumatic Spinal Cord Injury Population April 1, 2003 to March 31, 2004

Submitted by: Luchie Swinton, B.Sc.O.T. Neurorehabilitation Program Facilitator


Neurorehab Report 96

SPINAL CORD INJURY REHABILITATION PROGRAM (FMC Patient Care Unit 58) Traumatic Spinal Cord Injury Population General Population Descriptors 29 (55%) of patients with a spinal cord injury (SCI) diagnosis, admitted to the Tertiary Neurorehabilitation Unit sustained their injury from a traumatic cause. Following is a breakdown of the causes:

The population was predominantly male (83%) with both the average and median age being 44 years with a range of 18 – 85 years. The age range is described in the following chart.

Causes of Traumatic Injury (n=29)

45%

21%

31%

3%Motor vehiclerelated

Sports related

Falls

Other trauma

Almost half of the injuries were motor vehicle-related with falls being the second most common cause of injury.

At the time of injury, 7 patients were under 26 years of age, 17 between 26 and 60, and 5 were older than 60.

12 patients sustained a cervical level injury while 16 had a thoraco-lumbar injury.

Age at Time of Injury (n=29)

24%

17%42%

17%

25 and under

26 - 40

41 - 60

Greater than 60

Level of Injury (n=29)

55% 41% 3%0%

20%

40%

60%

Paraplegia

Quadriplegia

OtherSCI

Injury Level

% o

f Pat

ient

s



Services Received Therapy Services Standing orders exist on the unit, enabling all disciplines to determine which clients require their services. Based on the client-centred approach, only those services the client needs are provided. The following chart describes the extent each of the disciplines was involved in the care of the traumatic SCI population.

As the Tertiary Neurorehabilitation Service at the Foothills Medical Centre has a catchment area that includes all of southern Alberta and Southeastern BC, Southwest Saskatchewan, 41% of our population were non-CHR residents. This is a significant number as discharge planning is more complex when clients are not from our health region.

For 21 of our 29 clients, employment status at time of injury was reported. Of these, 62% were employed, 19% not working and another 19% were retired due to age or a disability.

Employment Status at Time of Injury(n=21)

134

4

Employed

Not Working

Retired

Region of Residence (n=29)

59%

34%

7%

Region 3

Other AB

Non-AB

All the patients attended Recreation Therapy. Almost all the patients received OT, PT and Social Work services, while a third of the patients accessed services of a registered dietitian and a psychologist.

Patients Attending Specific Therapies (n=29)

0%25%50%75%

100%

OT PT RecT S-LP SW PSYC RD

Disciplines

% o

f Pat

ient

s



While on the Tertiary Neurorehabilitation Unit, clients can access other services. The following chart details the services accessed by the traumatic SCI population. Rehabilitation Outcomes and Indicators Functional Outcomes Functional outcomes are measured on the Tertiary Neurorehabilitation Unit using the Functional Independence Measure (FIMTM). (Please refer to the Tertiary Neurorehabilitation Annual Report: Traumatic Brain Injury Population for a description of the FIMTM and its use on the Tertiary Neurorehabilitation Unit.) Using benchmarks set by the Uniform Data System for Medical Rehabilitation (UDS-MR), it can be noted that on admission, 76% (22) of our patients had a FIMTM score of less than 77 which puts them in the category of being severely disabled. At discharge, however, only 7 (24%) patients remained in that category.

The table on the left summarizes the FIMTM data for the traumatic SCI population.

Admission DischargeMean 67 94Median 58 103Range 35 - 111 37 - 124

FIM TM Scores (n=29)

0

30

60

90

1201

2 34

56

7

89

1011

1213

1415161718

1920

21

2223

2425

2627

28 29

Admission Scores Discharge Scores

Other Services Provided (n=29)

0%20%40%60%80%

100%

Family Conference

Weekend Pass

Home Visit

Day Pass

Clinic Follow-up

Services

% o

f Clie

nts

rece

ivin

g se

rvic

e



Further analysis of the FIMTM data shows that the average overall functional change in scores, from admission to discharge, for this population was 45%. When motor items are separated from the cognitive/social interaction items, the average change was 100% and 2% respectively. One must note that unless there are pre-morbid cognitive/social interaction deficits, the focus of rehab with this population is on the physical and psychosocial aspects, hence the difference in the two components. At discharge, 12 of the patients (37%), with scores of 108 or higher, were independent in the 18 FIMTM items while another 27% (8 patients), with scores between 90 and 107, required only set-up to complete the tasks. Another indicator of success is Length of Stay (LOS). Because the Tertiary Neurorehabilitation Unit is part of Acute Care in the CHR, both the rehabilitation length of stay (RLOS) and acute length of stay (Acute LOS) need to be considered. The efficiency of rehabilitation care can be calculated by dividing the functional gain, as measured by the FIMTM, by the RLOS. The average LOS Efficiency for this population was 0.44 with a median of 0.37. This means that patients gained an average of 0.44 FIMTM functional levels for each day that they were on the Tertiary Neurorehabilitation Unit.

Total Length of Stay (n=29)

0

100

200

300

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29Patients

LOS

in D

ays

AcuteLOS RehabLOS

Acute LOS RLOS Total LOSMean 28 94 122Median 20 86 106Range 1 - (81) 17-215 30 - 256

The average acute LOS is 28 days while the average RLOS is 94 days totaling 122 days in hospital on average for the traumatic SCI population. 7 patients (24%) remained in an acute care bed longer than 6 weeks while double that number (14) had a rehabilitation stay greater than 3 months. Only 4 patients (13%) had a RLOS > 150 days.



Discharge Delay When a traumatic SCI occurs, no one is prepared for its consequences. The SCI survivor and their families are required to make many changes in order to return to their community successfully. These changes range from housing adaptations to the need for ongoing assistance in self-care. As noted earlier, 63% of those discharged from the program needed daily help with the 18 FIMTM functional items. All of these changes entail a financial cost and not all our patients have access to funds for home renovations or for personal assistance. As such, they are dependent on government funding for care and/or equipment at best or they must wait for subsidized housing to become available. Our patients were discharged to the following locations: The delay in discharging patients from Unit 58 can also cause a similar delay in transfer of patients from acute care units. The date when patients are ready for transfer to Unit 58 was reported in 15 (51%) of the patients with a traumatic SCI diagnosis. 4 of the 15 were reported to have been ready for transfer but had to wait because of the unavailability of a bed on Unit 58. Of the 4, 2 waited for 1 day, one waited for 5 days and 1 other patient waited for 7 days, for a total of 14 acute care hospital days spent waiting for transfer to Unit 58.

Discharge for 10 of our patients was delayed for reasons outlined in the chart to the right. This accounted for usage of a total of 269 hospital days while waiting for discharge.

Reasons for Delay in Discharge (n=10)

2

1

3

2

2 Wait for ContinuingCare Wait for Equipment

Wait for HomeRonovationsOther Reasons

Unreported

Discharge Location (n=29)

59%14%

7%

3%

17%Home

Transitional LivingSettingContinuing Care

FMC Acute Unit

Acute Unit non-CHR

17 of our patients were able to return home: 3 by themselves, 11 with family, 2 with friends and 1 with an attendant. All of our patients resided at home prior to injury.



Outpatient Services When appropriate, outpatient therapies continue to be provided to our patients after discharge from Unit 58.

Almost a third of the population continued to be followed by the various rehabilitation disciplines as outpatients.

Access to Outpatient Services (n=29)

0%

10%

20%

30%

40%

OT PT RecT SW PSYCDisciplines



BRAIN INJURY REHABILITATION PROGRAM (FMC Patient Care Unit 58) Traumatic Brain Injury (TBI) Population

General Population Descriptors Of the 101 patients admitted for brain injury rehabilitation, 62% (n=63) were from a traumatic cause. The following is a breakdown of these causes: The average age of the group was 43 with clients ranging in age from 19 – 79. 62% of the population was male. The following chart shows their age distribution at time of injury:

36 of the 63 patients sustained their injury from a motor vehicle related incident while 17 had a fall. Assaults ranked as the third most common reason for a traumatic brain injury. 5 of the 63 (7%) sustained other major orthopaedic trauma with a primary diagnosis of brain injury.

40 of the patients were from Calgary, while another 6 were from other Region 3 communities. 22% (14) of the patients were from other health regions in Alberta, with 3 being from Saskatchewan, BC and Ontario respectively.

Age at Time of Injury (n=63)

22%

22%45%

11%

25 and under26 - 4041 - 60Greater than 60

Cause of Injury(n=63)

8%

27%

57%

3%2%

3%AssaultFallM otor Vehicle relatedSports relatedDrug overdoseUnknown

Region of Residence (n=63)

63%10%

22%

5%

CalgaryOther Region 3Other AlbertaNon-Alberta



Other Brain Injury Population Demographics Educational Attainment

Employment Status Other common characteristics among a brain injury population are the presence of substance abuse, a learning disability or possession of a criminal record. 18 (29%) of our patients were known to have a problem with substance abuse, 5% had a known learning disability and 12 % possessed a criminal record. Brain Injury Rehabilitation Outcomes/Indicators Severity of brain injury is one of the indicators influencing outcome. Although tertiary inpatient rehabilitation is indicated for patients with a more severe brain injury, it may be appropriate to provide these services to the mild to moderately brain injured population in order to adequately prepare them for a safe discharge location that will facilitate their continued rehabilitation. The Glasgow Coma Scale (GCS) is a standard scale applied at the outset that helps to determine severity of injury. It evaluates level of consciousness by assessing motor response, verbal response and eye opening.

Highest Educational Level Attained (n=63)

38%

52%

8% 2%

Less than Grade 12Grade 12UndergraduateGraduate

Our population’s educational profile supports research that shows lower educational attainment in the brain injury population. 90% of our population achieved no greater than a Grade 12 education.

Employment Status at Time of Injury (n=63)

67%

10%

13%

10%

EmployedStudentUnemployedRetired

At the time of injury, 42 of our 63 patients were employed, 6 were in school, 8 were not working, while another 6 were retired due to either age or a disability.



Another method of measuring severity of injury at the later stages of recovery is by looking at the length of Post-traumatic Amnesia (PTA). The longer the PTA, the more severe the injury. Patients’ level of cognitive functioning is assessed both on admission to and at discharge from the Tertiary Neurorehabilitation Unit using the Rancho Los Amigos Scale. The original scale, utilized up to the end of this fiscal year, is an 8-level scale with the following descriptors:

Severity of Injury Using the Glasgow Coma Scale

72%

14%

14%

Severe (<9)M oderate (9-12)M ild (13-15)

Using the GCS, 72% of our patients fall within the severe brain injury category. Our population was also made up of 14% with a mild brain injury and 14% with a moderate brain injury. This was based on a reporting rate of 90% (57 out of 63).

PTA was reported in only 60% (38) of our population. For those with a reported PTA, none were under 24 hours, which would categorize the brain injury as being either mild or moderate.

Level I – No response Level II – Generalized response Level III – Localized response Level IV – Confused/Agitated Level V – Confused, Inappropriate Non-agitated Level VI – Confused, Appropriate Level VII – Automatic, Appropriate Level VIII – Purposeful, Appropriate

Brain Injury Severity According to PTA (n=38)

11%

47%

42%Severe (1 - 7 days)

Very severe (>7 days)

Extremely Severe (>4weeks)

Rancho Los Amigos Scale Scores

0

10

20

30

40

II III IV V VI VII VIIIRancho Scale

# of

Pat

ient

s

Admission Discharge

(60 scores reported at admission, 54 at discharge)



Therapy Services Although there are standing orders for all disciplines to provide therapy services to all patients admitted to the Tertiary Neurorehabilitation Unit, not all disciplines are required by all patients.

Other Services The following services were also provided:

The chart on the left details the changes in cognitive function based on the Rancho Los Amigos Scale. 76% (41) of patients with reported Rancho Scores demonstrated an improvement in cognitive function at discharge.

The chart on the right summarizes the extent of the utilization of each of the disciplines with the brain injury population during their inpatient stay.

Utilization of Disciplines in Inpatient Rehabilitation (n=63)

97% 98% 100% 98% 94% 87%52%

0%20%40%60%80%

100%

OT PT RecT S-LP SW PSYC RDDisciplines

% u

tiliz

atio

n

Other Rehabilitation Services Provided (n=63)

13%

71%79%

8%

73%

0%20%40%60%80%

100%

FamilyConference

WeekendPass

Day Pass

HomeVisit

ClinicFollow-up

Rehabilitation Services

% o

f Pat

ient

s A

cces

sing

Se

rvic

e

Change in Rancho Los Amigos Scale Score at Discharge (n=54)

0%20%40%60%80%

Improved Unchanged Decreased

C o gnit ive F unct io n Status at D ischarge per R ancho Sco re



Functional Outcomes The rehabilitation team assesses function using the Functional Independence Measure (FIMTM), an 18 item instrument with a 7-point scale. This instrument is held by Uniform Data Systems for Medical Rehabilitation (UDS-MR). The team members receive training and must pass a test at 80% to be certified to use the instrument. The FIMTM is completed at admission and discharge. The patients’ scores are depicted in the following charts. Using benchmarks set by UDS, 35% (22) of the patients had a FIMTM score of less than 78 and therefore considered as having severe disability. At discharge, only 8% (5) patients were still in this category, showing an effective rehabilitation program. Scores greater than 107 indicate functional independence in the 18 FIMTM items. 51 patients had a FIMTM score indicating that they were independent with the 18 FIMTM items at discharge. A further breakdown of the FIMTM scores also demonstrates an average overall functional change of 56%, and specifically an average change of 66% and 47% in physical and cognitive/social interaction functional areas respectively. Length of Stay is another indicator that is monitored to determine the cost of rehabilitation. The average rehabilitation length of stay (RLOS) for this population was 42 with a median of 32 days and a range of 6 – 202 days. There were 7 patients with a RLOS of less than 15 days and 5 patients with a RLOS of greater than 90 days. In the Calgary Health Region, Tertiary Neurorehabilitation is a part of Acute Care. As such, the cost of the patient’s acute care is relevant since delays in transfer to the Tertiary Neurorehabilitation Unit can affect the patient’s total cost of care. The following chart summarizes the LOS data for the TBI Population.

FIM TM Scores (n=63)

0

30

60

90

1201

2 3 4 56

78

910

111213141516171819

2021

2223

2425

26272829303132333435363738

3940

4142

4344

454647484950

515253

5455

5657

5859

60 6162 63

Admission Scores Discharge Scores



The average Acute LOS is 31 days with a median of 21 days and a range of 9 - 117 days. 2 of the patients were transferred directly to the Tertiary Neurorehabilitation Unit from an acute hospital outside the CHR while 23 patients spent greater than 30 days on an acute CHR unit. The average Total LOS for patients whose full hospitalization (acute and tertiary rehab) were in a CHR facility(s) is 74 days with a median of 56 days and a range of 21 – 292 days. 10 patients had a total LOS of greater than 120 days. The efficiency of rehabilitation service (Length of Stay Efficiency) can be calculated by dividing the difference between the discharge and admission FIMTM scores by the RLOS. The higher the number, the greater the efficiency. The average LOS Efficiency for the TBI population is 0.71 with a median of 0.64 and a range of 0 – 2.33. The LOS Efficiency also refers to the rate of functional change achieved by the patients per day. It can be noted that some patients did not change functionally over their whole rehabilitation stay while some changed at a rate of 2.33 FIM scale levels per day. There are many reasons for an overextended RLOS. Patients who remain in Tertiary Rehabilitation even after they are ready for discharge are identified and the reason for the delay in discharge identified. 8 patients experienced a delay in discharge ranging from 1 – 31 days for a total of 141 hospital days of stay. The reasons for delay were as follows:

Reasons:

1 - Awaiting a bed in Continuing Care 2 - Awaiting a bed in Ponoka Brain Injury

Program 3 - Awaiting a bed in a local hospital 4 - Unknown

Reasons for Delay in Discharge (n=8)

0%10%20%30%40%50%60%

Reason 1 Reason 2 Reason 3 Reason 4

% d

elay

ed

Total Length of Stay of TBI Patients (n=63)

0

50100

150

200250

300

1 5 9 13 17 21 25 29 33 37 41 45 49 53 57 61

Patients

LOS in

Day

s

AcuteLOS RehabLOS



When there are delays in discharging from Tertiary Rehabilitation, patients who are ready and awaiting transfer to the Tertiary Rehabilitation Unit may also experience a delay. 32 patients awaited transfer with an average of 4 days wait and a median of 1 day. The range for waiting for transfer from an acute care unit was between 1 and 16 days. One of the tasks of the rehabilitation team is to determine the amount of supervision the client will require at discharge. This is to ensure client and family safety as well as to facilitate an environment for continued rehabilitation. The Supervision Rating Scale (SRS) is used to establish the level of supervision required at discharge. For many reasons, however, the supervision at the discharge environment does not always match the recommendations. Whenever appropriate, patients continue to receive outpatient therapy services at discharge. The following chart represents the percentage of patients who received the service.

Discharge location (n=63)

76%

3%

2%

2%

6%11%

Home

Continuing carefacilityAcute Unit - FMC

Acute Unit - non CHR

Other RehabilitationProgramOther

76% of patients were discharged home, 42 with family/relatives, 2 with friends, and 4 alone. All of the patients lived at home prior to their injuries.

36 of the 52 patients with reported SRS scores received the appropriate level of supervision. 11 received more supervision than was recommended while 5 received less than the recommended level of supervision at the discharge location.

Although 24 of a possible 37 patient accessed outpatient services of 24 of the 63 patients accessed outpatient services, it must be noted that 17 patients (26%) resided outside the CHR, and 9 patients (14%) were discharged to other inpatient rehabilitation programs.

Outpatient Therapy Services (n=63)

0%

10%

20%

30%

40%

OT PT RecT S-LP SW PSYC

Disciplines

% o

f Pat

ient

s

Actual Supervision at Discharge Location as Compared to Recommendations (n=52)

21%

69%

10%0%

20%

40%

60%

80%

Greater Appropriate Lesser

% o

f Pat

ient

s

Injury Prevention and Control Services Report

April 2003 to March 2004 Prepared by: Sherry Elnitsky, Research Project Coordinator Christoph Beck, Research Project Coordinator Nancy Staniland, Injury Prevention and Control Leader Injury Prevention and Control Services Healthy Living, Southeast Community Portfolio


Injury Prevention & Control Report 110

Executive Summary This report is the fourth annual Injury Prevention and Control Services Report and represents a continued refinement of injury surveillance, data analysis and reporting. The report offers a more comprehensive analysis of injury by mechanism and an analysis of injuries that cross over specified injury mechanisms, namely workplace injuries and sport and recreational injuries. Major injury prevention activities and strategies that have been initiated or maintained over the past year are reviewed and draft regional injury targets consistent with the Framework for a Healthy Alberta1 are proposed. Three primary data sets are used: hospital utilisation, emergency department utilisation and Alberta Vital Statistics mortality data. Rates are defined using Alberta Health and Wellness population registry data. The utilisation data represent residents of the Calgary Health Region (April 2003 boundaries) who have utilised acute care facilities in Calgary for the period April 2003 to March 2004. The most recent mortality data is for the calendar year 2002 and is based on Calgary Health Region boundaries prior to April 2003. Data Highlights Despite changes to the manner in which injury cases are selected and to the regional boundaries, the overall profile of injuries in the Calgary Health Region remained relatively consistent and is similar to the provincial and national profile. Injuries are the leading cause of death for people between the ages of 1 and 49 years and account for the largest number of years lost due to premature death when compared with all other diseases in the same age group. In 2002, there were 350 injury-related fatalities to Calgary Health Region residents, which represented a mortality rate of 35.3 per 100,000 people. The death rate has increased from 2001 but dropped slightly from 2000. The potential years of life lost per death, on average, has followed a similar pattern across time. Injury deaths accounted for 7% of the total deaths in the region. Over the last three years, suicide has accounted for more than a third of all injury-related deaths. In 2003/2004, the total number of hospitalisations for all injury causes was 6,782, which represents a hospitalisation rate of 604 per 100,000 people. There was a total of 61,178 injury-related emergency department visits, resulting in a rate of 5,452 per 100,000 people. Overall, falls and transportation were the most common injury cause for both hospital and emergency department utilisation. Males are, for the most part, at higher risk of sustaining an injury than are females, particularly in the workplace and as victims of violence. There is often a substantial increase in injuries between the ages of 15 and 24, a decline though middle ages and a subsequent increase in older age groups. There are, however, a number of exceptions to this overall trend. With respect to gender, females have a greater risk than males for both suicide-related hospitalisation and emergency department utilisation, particularly in the 15-24 year age group. Females, between the ages of 0-4 are also at greater risk for a violence-related injury that may result in either hospitalisation or an emergency department visit. With regards to age, fall-related injuries resulting in hospitalisation remain relatively unchanged throughout most of the life span but increase quite dramatically beyond age 65, particularly for females. Emergency department rates are higher in the young, decline through young adulthood

1 Alberta Health and Wellness (2003). Framework for a Healthy Alberta.



and middle age and then increase in older age groups, again particularly for females. There is also a marked contrast in pattern for hospitalisation and emergency department rates for poisoning. Poisoning-related hospitalisations increase over the life span, while emergency department rates for poisoning are higher in younger ages and then start to decrease over the life span. Injury Prevention and Control Services Activity Highlights Injury Prevention and Control Services activity is organised around key objectives, which are linked to both priority injury issues affecting the population and to identify risk groups. The objectives also reflect health promotion outcomes that are necessary to advance the overall goal of reducing the frequency and severity of injuries in the Calgary Region. A common business plan is developed and implemented across the service team, with the majority of strategies involving collaboration with a number of regional health authority and community partners. Selected activity highlights are presented in the following areas: injury data, creating environments to promote risk management, capacity building for injury prevention, intentional injury prevention, fall prevention and traffic safety. Recommendations and Alignment with Provincial Directions for Injury Control Injury Prevention and Control Services has acted upon the direction of both provincial and senior portfolio management levels to align regional injury prevention work with provincial indicators and to make specific recommendations on appropriate targets for the Calgary Health Region. These targets as well as additional regional indicators are outlined. Taken together, these targets provide valuable templates for future action and an organising structure to report progress on injury reduction in subsequent years. This will, however, require the coordinated efforts of a number of partners beyond the health sector in order to achieve the outcomes that have been set. Injury Prevention and Control Services will continue to demonstrate leadership in the core areas of its mandate and to advocate for others to take action within their roles.



Introduction Following the recent restructuring of regional business units, Injury Prevention and Control Services is now part of the Healthy Living business unit of the Southeast Community Portfolio. Prevention of injuries continues to be one of the identified priority areas within the new business unit as injuries contribute significantly to death and health care utilisation rates and have an enormous impact on the quality of life of all residents of the region. An Injury Prevention and Control Services Team of 10 staff (8.5 FTE equivalent) work across a number of regional programs and services and with diverse community partners to reduce the likelihood, frequency and severity of injuries in the Calgary Health Region. This report is the fourth annual Injury Prevention and Control Services Report and represents a continued refinement of injury surveillance, data analysis and reporting. The report offers a more comprehensive analysis of injury by mechanism and an analysis of injuries that crosses over specified injury mechanisms, namely workplace injuries and sport and recreational injuries. Draft regional injury targets consistent with the Framework for a Healthy Alberta2 are also proposed and establish recommendations for future action. The broad purposes of the Injury Prevention and Control Services Report are to highlight the following: Population based injury data including mortality, hospitalisations and emergency department visits Injury mechanisms including falls, transportation, suicide, violence and other injury Nature of injuries by mechanism Workplace injuries Sport and recreational injuries Population based injury data by age group and gender Year-to-year trends where possible Key data observations and implications Major injury prevention activities and strategies that have been initiated or maintained over the past

year Current regional data for the injury targets in the Framework for a Healthy Alberta Draft regional targets consistent with the Framework Recommendations for future action The injury mechanisms highlighted in this report are consistent with those presented in previous reports. These target areas represent types of injuries that, overall, contribute to a large proportion of morbidity and mortality in the region. Unfortunately there is always a significant proportion of injuries that are relatively infrequent or unspecified; therefore the selected injury categories represent only part of the total injury picture. In general, year-to-year reporting on the same primary injury mechanisms is important for trending and comparability, although the change in coding systems and boundaries introduce some challenges (see Appendix A).

2 Alberta Health and Wellness (2003). Framework for a Healthy Alberta.



Methodology

Three primary data sets were used: hospital utilisation, emergency department utilisation and Alberta Vital Statistics mortality data3. Rates were defined using Alberta Health and Wellness population registry data.

Utilisation Data The data presented includes residents of the Calgary Health Region (April 2003 boundaries) who have utilised acute care facilities in Calgary4 for the period April 2003 to March 2004. The regional boundaries have expanded and will thus affect comparability with previous reports (see Appendix A for data considerations). Comparisons should be limited to those rates that have been standardised (see Appendix B for data definitions). ICD-10-CA codes were used to select injury cases. Where more than one injury code was assigned to a specific case, the first code encountered was used to classify the visit5. Variables analysed were external cause of injury, nature of injury, age, and gender. Based on types of injuries known to contribute to a large proportion of morbidity and mortality in the region, external cause of injury was grouped according to the following categories: all injuries, falls, transportation, suicide, violence and other injury (i.e., injuries other than the identified mechanisms). From the injury cases selected based on ICD-10-CA code, workplace injuries were identified by method of payment (i.e., Workers’ Compensation Board payment) and sport and recreational injuries were selected based on 126 supplementary codes defined by Alberta Centre for Injury Control and Research (ACICR). Because workplace and sport and recreational injuries were identified through this two-stage process, these injuries are not mutually exclusive of the other injury areas and, as such, are presented separately.

Mortality Data Mortality data were available, by calendar year, for the period 2000 to 2002, based on Calgary Health Region boundaries prior to April 2003. ICD-10-CA was used to select the mortality cases. Variables analysed were external cause of injury, year, and gender. External cause of injury was grouped according to the same categories as the injury data (see Appendix B). All analyses will focus primarily on injury rates or proportions, except where numbers are very small or where the population at risk is not well defined (see Appendix C for the number of injuries by mechanism). Rates account for the relative size of population segments and, therefore, will allow for meaningful comparison across segments of the population (see Appendix B). Crude rates are used to provide the overall context, category specific rates are used to provide more accuracy within population segments and standardised rates are used to compare different populations (across time or geographical location).

3 Injury, mortality and population data have been supplied by Quality Improvement and Health Information, Calgary

Health Region. All data may be subject to update and/or revision. 4 Utilisation data is not currently representative of the entire region as data from the rural acute care facilities is not yet

available (see Appendix A for a more complete discussion of this issue). 5 It is possible that there may be more than one code associated with an injury. For example, a ski-related injury may

be considered both a transportation-related and a fall-related injury.



Injury Data

Data Overview Despite changes to the manner in which injury cases are selected and to the regional boundaries, the overall profile of injuries in the Calgary Health Region remains relatively consistent and is similar to the provincial and national profile. Injuries are the leading cause of death for people between the ages of 1 and 49 years and account for the largest number of years lost due to premature death when compared with all other diseases in the same age group. In 2002, the most recent year of available mortality data, there were 350 injury-related fatalities to Calgary Health Region residents (based on Region 4 boundaries) which represents a mortality rate of 35.3 per 100,000 people. There was a total of 11,932 potential years of life lost (PYLL) related to injury causes, while, on average, there were 38 years of PYLL per injury death. Injury deaths accounted for 7% of the total deaths in the region. The total number of hospitalisations for all injury causes was 6,7826, which represents a hospitalisation rate of 604 per 100,000 people (see Figure 1). There was a total of 61,178 injury-related emergency department visits7, resulting in a rate of 5,452 per 100,000 people (see Figure 2). For both hospitalisation and emergency department visits, fall-related injuries represent the majority of cases (see Figures 1 & 2). Injury-related hospitalisation accounted for 8% of all hospitalisations, while injury-related emergency department visits accounted for 24% of all emergency department visits in the region.

Figure 1: Injury-Related Hospitalisations and Crude Hospital Utilisation Rate per 100,000 People, Calgary Health Region Residents (Region 3 Boundaries),

2003/20046782

3215

851505 341

604287 76 45 30

0

1000

2000

3000

4000

5000

6000

7000

All Injuries Falls Transportation Suicide Violence

Injury Mechanism

Num

ber o

f Eve

nts

Hospital Visits Hospitalisation Rate

6 This represents 82% of all injury-related visits to Calgary hospitals (i.e., the remaining 18% of visits were to non-

residents of the region). 7 This represents 92% of all injury-related visits to Calgary emergency departments (i.e., the remaining 8% were to

non-residents of the region).



Figure 2: Injury-Related Emergency Department Visits and Crude Emergency Department Utilisation Rate per 100,000 People, Calgary Health Region Residents

(Region 3 Boundaries), 2003/2004

61178

18353

62531152 2775

54521636 557 103 247

0

10000

20000

30000

40000

50000

60000

70000


Injury Mechanism

Num

ber o

f Eve

nts

Emergency Department Visits Emergency Department Visit Rate

In order to provide a meaningful comparison, injury rates for the past two years were age-standardised using Alberta 2002/2003 year end population (see Appendix B). As indicated in Figures 3 and 4, injury rates for both hospitalisations and emergency department rates have decreased over the last year. The one exception to this pattern is violence where there was no change observed.

Figure 3: Age Standardised Injury-Related Hospitalisation Rate per 100,000 People, Calgary Health Region Residents, 2002/2003 and 2003/2004

658

312

77 5830

623

305

7644 30

0

100

200

300

400

500

600

700


Injury Mechanism

Num

ber o

f Eve

nts

2002/2003 2003/2004



Figure 4: Age Standardised Injury-Related Emergency Department Visit Rate per 100,000 People, Calgary Health Region Residents, 2002/2003 and 2003/2004

6086

1848

619117 268

5518

1693

557101 246

0

1000

2000

3000

4000

5000

6000

7000


Injury Mechanism

Num

ber o

f Eve

nts

2002/2003 2003/2004

Figures 5 and 6 show the proportion of injury-related hospitalisation and emergency department visits by injury mechanism. These figures indicate the proportion of other injuries and, in an attempt to refine the injury picture represented in the report, the most common specified injury mechanisms in this category are noted for both hospitalisation and emergency department visits. The three most common other causes of injury resulting in either hospitalisation or emergency department visits are the same (although their ranking differs): overexertion/strenuous or repetitive movements, poisoning, and struck by object or people.

Figure 5: Proportion of All Injury-Related Hospital Visits by Injury Mechanism, Calgary Health Region Residents (Region 3 Boundaries),

2003/2004 (n=6782)

Falls47%

Transportation13%

Suicide7%

Violence5%

Other1

28%

1 The most common specified injury mechanisms represented in this category are overexertion/strenuous or repetitive movements (16%), poisoning (13%) struck by objects/people (8%), foreign body in natural opening (7%), struck by objects/people in sports (6%), and contact with cutting/piercing objects (3%). The remainder of the injuries are relatively infrequent (less than 3%) or unspecified.



Figure 6: Proportion of All Injury-Related Emergency Department Visits by Injury Mechanism, Calgary Health Region Residents (Region 3 Boundaries),

2003/2004 (n=61178)

Falls30%

Transportation10%

Suicide2%

Other1

53%

Violence5%

1 The most common specified injury mechanisms represented in this category are overexertion/strenuous or repetitive movements (16%), struck by objects/people (14%), poisoning (10%), struck by objects/people in sports (10%), contact with cutting/piercing objects (9%), foreign body in natural opening (9%) and contact with animals/plants (4%). The remainder of the injuries are relatively infrequent (less than 3%) or unspecified.

Unlike previous reports, workplace injuries are presented independent of the injury mechanisms. These injuries are defined through a two stage process: first by external cause of injury code (ICD-10-CA) and then by method of payment (i.e., Worker’s Compensation Board). As such, workplace injuries can also be categorised by injury mechanism and, therefore, are not mutually exclusive from the highlighted injury mechanisms. There were a total of 235 workplace-related hospitalisations which represents a rate of 27 per 100,000 people between the ages of 15 to 74. The total number of workplace-related emergency department visits was 3799 for persons aged 15 to 74, resulting in a rate of 442 of per 100,000 people within this age range. As indicated in Table 1, half the workplace-related hospitalisations were fall-related while there was much more variability in cause of injury for workplace-related emergency department visits. Table 1: Workplace Injuries by Mechanism, Calgary Health Region Residents (Region 3

Boundaries), 2003/2004

Hospitalisation Emergency Department Visits Injury Mechanisms

N % N %Falls 119 50% 664 17% Transportation 18 8% 110 3% Violence 0 0% 47 1% Other Mechanisms Struck by objects/people (non-sports) 19 8% 529 14% Overexertion/strenuous or repetitive movements 16 7% 447 12% Contact with cutting piercing objects 7 3% 507 13% Foreign body in natural opening 6 3% 416 11% Poisoning 0 0% 136 4% Other (less than 3% or unspecified) 50 21% 943 25% Total 235 100% 3799 100%



Injury-Related Mortality Mortality data are collected by Alberta Health and Wellness and are presented by calendar year. Since ICD-10-CA was adopted for mortality data in the year 2000, there are three years of comparable data. As indicated in Table 2, the death rate has increased from 2001 but dropped slightly from 2000. On average, the PYLL per death has followed a similar pattern across time. Table 2: Injury-Related Mortality, Calgary Health Region Residents (Region 4), 2000-

2002 Calendar Year

Injury Mortality 2000* 2001* 2002 Total deaths (all causes) 4589 4581 4703 Injury-related deaths 337 320 350 Crude mortality rate 35.8 33.1 35.3 Age-standardised mortality rate 36.6 33.7 35.8 Total potential years of life lost (PYLL) 11,775 11,653 11,932 Average potential years of life lost 37.6 39.6 37.5

* Mortality data for 2000 and 2001 has been revised. Figure 7 presents the most common underlying causes of injury death. Over the last three years, suicide has accounted for more than a third of all injury-related deaths. This figure also indicates the proportion of other injuries; the most common specified causes of injury death in this category are noted. In each year, poisoning and threats to breathing are the most common causes of other injury resulting in death. In 2000, drowning is also an identified cause of death.

Figure 7: Proportion of All Injury-Related Deaths by Injury Mechanism, Calgary Health Region Residents (Region 4 Boundaries), 2000 to 2002

6%

20%

35%

5%

34%

4%

20%

36%

4%

35%

6%

19%

37%

3%

35%

0%

5%

10%

15%

20%

25%

30%

35%

40%

Falls Transportation Suicide Violence Other*

Injury Mechanism

2000 2001 2002

* The most common specified injury mechanisms represented in this category by year are: 2000: poisoning (9%), threats to breathing (inluding suffocation) (4%) and drowning (3%); 2001: poisoning (13%) and threats to breathing (including suffocation) (3%); 2002: poisoning (12%) and threats to breathing (including suffocation) (4%). The remainder of the other injuries in each year are relatively infrequent (less than 3%) or unspecified.



Injury-Related Hospitalisations and Emergency Department Visits This section presents injury-related hospitalisations and emergency department visits for all injuries and each of the four injury mechanisms (falls, transportation, suicide and violence) by age and gender. The nature of injury (i.e., the physical characteristics of the injury) by mechanism is also considered. In an attempt to define more of the total injury picture, there is a focus on injury-related poisonings. Finally, workplace injuries and sport and recreation injuries are analysed in more detail. While service providers will have an interest in absolute utilisation, the following analyses will focus primarily on injury rates (see Appendix C for absolute utilisation). Rates account for the relative size of the population segments and, therefore, will allow for meaningful comparison across segments of the population. Caution should be exercised when interpreting utilisation because the injury utilisation data are based on frequency of visits. As such, a large number of visits does not provide information about the severity of the injury (see Appendix A). All Injuries Overall, injury-related hospitalisation tends to increase with age. In general, males appear to be more at risk for hospitalisation, particularly between the ages of 15-24, until they reach 64 (see Figure 8). From age 65, females experience an increasing risk for hospitalisation due to injury.

Figure 8: Injury-Related Hospitalisations: Age and Gender Specific Utilisation Rate per 100,000 People, Calgary Health Region Residents (Region 3 Boundaries),

2003/2004

241 214 287

2806

6014

852641 633

363 341 424 606993

266 339593 637

837

1822

4773

0

1000

2000

3000

4000

5000

6000

7000

0-4 5-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 85+

Age Groups

Num

ber o

f Eve

nts

Female Male



Injury-related emergency department visits tend to be higher at younger ages, with the exception of visits to those over 85 (see Figure 9). Males appear to be more at risk for injury-related emergency department visits at younger ages, particularly between 15 and 24 years. After age 24, risk for an injury-related emergency department visit decreases with age for both genders, until age 65 where females tend to have more injury-related emergency department visits than males.

Figure 9: Injury-Related Emergency Department Visits: Age and Gender Specific Utilisation Rate per 100,000 People, Calgary Health Region Residents, (Region 3

Boundaries) 2003/2004

6906

13230

85238078

10877

7284

5425

40093257 31043658

3137300030363721

56445347

7185

11387

4971

0

2000

4000

6000

8000

10000

12000

14000

16000

0-4* 5-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 85+

Age Groups

Num

ber o

f Eve

nts

Female Male*Gender missing for one case.

Relative Utilisation Relative utilisation rates are useful because utilisation rates for specific gender/age groups can be compared to the entire population. Table 3 presents both the category specific utilisation rates and the relative utilisation rates for both hospitalisation and emergency department visits. As indicated in Table 3, serious injuries requiring hospitalisation are over-represented in the ageing population (65+) for both males and females. Males between the ages of 15 and 44 years also require hospitalisation for injury more often relative to the rest of the population. For injuries requiring a visit to an emergency department, males up to the age of 34 years are over-represented. For females, this trend is true below age 4 and above age 75.



Table 3: Unadjusted and Relative Utilisation Rates for Hospitalisations and Emergency Department Visits, Calgary Health Region Residents (Region 3 Boundaries), 2003/2004

All Injury Hospitalisations All Injury Emergency Department Visits Unadjusted

Utilisation Rates1 Relative Utilisation

Rates2 Unadjusted

Utilisation Rates1 Relative Utilisation

Rates2 Age Group

Male Female Male Female Male Female Male Female 0-4 years 0.002655 0.002410 0.439337 0.398757 0.085230 0.071850 1.563303 1.317881 5-14 years 0.003385 0.002140 0.560085 0.354039 0.080783 0.053467 1.481742 0.980700

15-24 years 0.008523 0.003630 1.410260 0.600662 0.108768 0.056444 1.995048 1.03529925-34 years 0.006410 0.002866 1.060513 0.474163 0.072838 0.037210 1.336008 0.682519

35-44 years 0.006334 0.003408 1.048016 0.563838 0.054246 0.030356 0.994991 0.556790

45-54 years 0.005935 0.004245 0.981923 0.702353 0.040087 0.029998 0.735290 0.550224

55-64 years 0.006369 0.006059 1.053858 1.002506 0.032566 0.031374 0.597337 0.575474

65-74 years 0.008373 0.009932 1.385444 1.643382 0.031040 0.036583 0.569336 0.671011

75-84 years 0.018216 0.028059 3.013934 4.642544 0.049711 0.069065 0.911818 1.26680185+ years 0.047732 0.060138 7.897467 9.950109 0.113869 0.132303 2.088617 2.426723

1 Age and gender specific utilisation rates refer to the number of hospitalisations or emergency department visits that occur for each gender in each age group. They are derived by dividing the number of visits by the number of people in that gender-age group.

2 Relative utilisation rates are generated from the age group specific utilisation rate divided by the total population rate (i.e., without age or gender breakdown). This rate is 0.00604391 for hospitalisations and 0.05451906 for emergency department visits. The relative utilisation rate, therefore, describes the likelihood that someone in that gender-age group will be hospitalised or visit the emergency department with an injury, when compared to the entire population.

Falls Overall, fall-related hospitalisation rates increase sharply after age 65, particularly for females (see Figure 10). Between the ages of 5 and 54, males tend to be hospitalised more often for fall-related injuries than females, particularly in the 15 to 24 year old age group.

Figure 10: Fall-Related Hospitalisations: Age and Gender Specific Utilisation Rate per 100,000 People, Calgary Health Region Residents (Region 3 Boundaries),

2003/2004

87 79 74 78 117

761

2323

5365

87 139 182 167 185 347223

3931

1349

484329232

0

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3000

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5000

6000

0-4 5-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 85+

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Female Male



Fall-related emergency department visit rates are relatively high from birth to 14 years of age for both genders, although males tend to be at higher risk than females (see Figure 11). Rates for both genders are relatively low between 25 and 54 but then start to increase quite dramatically with age, especially for females.

Figure 11: Fall-Related Emergency Department Visits: Age and Gender Specific Utilisation Rate per 100,000 People, Calgary Health Region Residents (Region 3


2170

4982

10541

3253 29851936

1158 1027 10201442

1016788800114021512720

8080

3094

14441056

0

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6000

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12000

0-4 5-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 85+

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Female Male

Because falls account for a large proportion of injuries (see Figures 5 and 6), more in-depth analyses were conducted. Fall types are highlighted and health service utilisation for fall-related injuries is presented. As indicated in Figure 12 and 13, the most common type of fall is a slip, trip or stumble. It is reasonable to expect that the type of fall would vary with age8. In general, falls in younger ages (i.e., below 25) tend to be from different levels while in older age groups, falls tend to be from the same level. More specifically, falls from furniture are the most common for 0-4 year olds, falls from playground equipment are the most common for 5-9 year olds, and sport-related falls are most common for 10-14 and 15-19 year olds. After age 25, slips, trips and stumbles are the most common type of fall.

Figure 12 : Proportion of Fall-Related Hospitalisations by Fall Type, Calgary Health Region Residents (Region 3 Boundaries), 2003/2004

(n=3215)

unspecified falls10%

sports-related falls8%

slips, trips, stumbles38%other falls, different

levels12%

falls from furniture4%

falls from steps/stairs9%

falls from playground equipment

2%

other falls, same level17%

8 For the purpose of these analyses, age has been regrouped into categories consistent with the pattern of fall frequency

(i.e., 0-4, 5-9, 10-14, 15-19, 20-24, 25-64, and 65+).



Figure 13: Proportion of Fall-Related Emergency Department Visits by Fall Type, Calgary Health Region Residents (Region 3

Boundaries), 2003/2004 (n=18353)

unspecified falls15%

sports-related falls13%

slips, trips, stumbles25%

other falls, different levels12%

falls from furniture6%

falls from steps/stairs11%

falls from playground equipment

4%

other falls, same level14%

Tables 4 and 5 present health service utilisation for fall-related injuries by age and against total utilisation. As indicated in these tables, for those 65+, 79% of the hospitalisations and 65% of the emergency department visits were fall-related. Consistent with the difference in type of fall, the resulting injury also differs by age. For those under 25, the most common fall-related injury is for a fracture of the arm, for those aged 25-64, it is a fracture of the lower limb and for those aged 65+, it is a fracture of the femur. Table 4: Fall-Related Hospital Utilisation by Age, Calgary Health Region Residents


Age Hospital Utilisation

< 24 Years 25-64 Years 65+ Years Total

All Visits (all cause) 26767 40387 20678 87832

Injury-Related Visits 1550 3267 1965 6782

Proportion of All Visits 6% (1550/26767)

8% (3267/40387)

10% (1965/20678)

7.7% (6782/87832)

Fall-Related Visits 426 1234 1555 3215

Proportion of All Injury Visits 28% (426/1550)

38% (1234/3267)

79% (1555/1965)

47% (3215/6782)

Fall-Related Visits: Nature of Utilisation With Fracture of Femur (excluding shaft and epiphysis) 9 88 649 746

Proportion of all Fall-Related Visits 2% (9/426)

7% (88/1234)

42% (649/1555)

23% (746/3215)

With Fracture of Arm (shoulder, upper arm/forearm, wrist, hand) 194 281 168 643


23% (281/1234)

11% (168/1555)

20% (643/3215)

With Fracture of Lower Limb (lower leg, ankle, foot) 97 524 166 787


43% (524/1234)

11% (166/1555)

25% (787/3215)



Table 5: Fall-Related Emergency Department Utilisation by Age, Calgary Health Region Residents (Region 3 Boundaries), 2003/2004

Age Emergency Department Utilisation

< 24 Years 25-64 Years 65+ Years Total

All Visits (all cause) 95910 116416 40273 252599

Injury-Related Visits 28472 27268 5438 61178

Proportion of All Visits 30% (28472/95910)

23% (27268/116416)

14% (5438/40273)

24% (61178/252599)

Fall-Related Visits 8301 6494 3558 18353

Proportion of All Injury Visits 29% (8301/28472)

24% (6494/27268)

65% (3558/5438)

30% (18353/61178)

Fall-Related Visits: Nature of Utilisation With Fracture of Femur (excluding shaft and epiphysis) 35 100 618 753

Proportion of all Fall-Related Visits 0.4% (35/8301)

2% (100/6494)

17% (618/3558)

4% (753/18353)

With Fracture of Arm (shoulder, upper arm/forearm, wrist, hand) 2355 1319 588 4262


20% (1319/6494)

17% (588/3558)

23% (4262/18353)

With Fracture of Lower Limb (lower leg, ankle, foot) 501 897 238 1636


14% (897/6494)

7% (238/3558)

9% (1636/18353)

Transportation Overall, males tend to require hospitalisation for a transportation-related injury more often than females, particularly between the ages of 15-24 and over 85 (see Figure 14). Rates for females are highest between 15-24 and 75-84. Similar to the pattern for hospitalisation, males are seen at the emergency department for a transportation-related injury more often than females (see Figure 15). Emergency department visit injury rates for both males and females are highest in the 15 to 24 year age group but tend to decrease after this point.

Figure 14: Transportation-Related Hospitalisations: Age and Gender Specific Utilisation Rate per 100,000 People, Calgary Health Region Residents (Region 3 Boundaries),

2003/2004

1236

7846 43 52 58 66

79

4120

68

191

11591 94

70 65

118

312

0

50

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250

300

350

0-4 5-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 85+

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f Eve

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Female Male



Figure 15: Transportation-Related Emergency Department Visits: Age and Gender Specific Utilisation Rate per 100,000 People, Calgary Health Region Residents (Region 3


242

912

1199

883

575465

310 320 281

149

266282315393353

539

807

435

196296

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Female Male

Not surprisingly, the majority of transportation-related hospitalisations and emergency department visits are due to motor vehicle collisions (68% and 67% respectively). The remaining injuries are primarily due to pedal and pedestrian-related incidents, and only a small proportion of transportation-related injuries are the result of rail-related or other incidents (see A Profile of Transportation-Related Injuries in the Calgary Health Region 1997/98-2002/03 for a detailed analysis of transportation-related injuries by mode of transport). Suicide Risk of hospitalisation due to suicide-related injury is more likely for both males and females between the ages of 15 and 44, with rates peaking in the 15-24 year old group (see Figure 16). However, unlike the pattern for the other injury mechanisms, females have a greater risk than males for suicide-related hospitalisation and emergency department utilisation (see Figure 17).

Figure16: Suicide-Related Hospitalisations: Age and Gender Specific Utilisation Rate per 100,000 People, Calgary Health Region Residents (Region 3 Boundaries),

2003/2004

0

30

109

6759

46

29

16 20

008

6762

49

3829

2214

31

0

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40

60

80

100

120

0-4 5-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 85+

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f Eve

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Female Male



Figure 17: Suicide-Related Emergency Department Visits: Age and Gender Specific Utilisation Rate per 100,000 People, Calgary Health Region Residents (Region 3


0

51

317

187

134

103

48 36 3014

014

184

109 108

5643

25 21 31

0

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0-4 5-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 85+

Age Groups

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Female Male

Violence Overall, violence-related hospitalisation and emergency department utilisation follow a similar pattern in that males experience much higher levels of violence-related injury than females, particularly after the age of 15 (see Figures 18 & 19). Injury rates peak in the 15 to 24 year age group, where there is also the greatest difference between males and females. It is interesting to note that between the age of 0 and 4, females are more at risk for violence-related injuries than males.

Figure 18: Violence-Related Hospitalisations: Age and Gender Specific Utilisation Rate per 100,000 People, Calgary Health Region Residents (Region 3 Boundaries),

2003/2004

24

314 11 16

7 4 315

09

3

149

74

56

28

10 14 14

31

0

20

40

60

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100

120

140

160

0-4 5-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 85+

Age Groups

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f Eve

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Female Male



Figure 19: Violence-Related Emergency Department Visits: Age and Gender Specific Utilisation Rate per 100,000 People, Calgary Health Region Residents


63 50 52 20 44 273584

1184

547

326

14978 36 14

12578

138201

360

0

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600

800

1000

1200

0-4 5-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 85+

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Female Male

Nature of Injury The previous sections have presented major cause of injury but without a consideration of the nature or type of injury sustained (i.e., the physical characteristics of the injury). Tables 6 and 7 compare the most common nature of injury by the injury mechanisms considered for hospitalisation and emergency department visits. Limb fractures accounted for just over 70% of fall-related injuries and 39% of transportation-related injuries requiring hospitalisation (see Table 6). Poisoning accounted for a large majority of suicide-related injuries (84%) and head and neck fractures accounted for 30% of the violence-related injuries.

Table 6: Most Common Nature of Injury by Injury Mechanisms- Hospitalisation, Calgary Health Region Residents (Region 3 Boundaries), 2003/2004

Injury Mechanism Most Common Nature of Injury

Falls 1. Fracture - limbs (71%) 2. Fracture - trunk level (9%) 3. Intracranial injury (4%)

Transportation 1. Fracture - limbs (39%) 2. Intracranial injury (15%) 3. Fracture - trunk level (12%)

Suicide 1. Poisoning (84%) 2. Open wound of limbs (4%) 3. Fracture of limbs (2%) 3. Other/unspecified effects, certain

early complication of trauma (2%)

Violence 1. Fracture – head/neck level (30%) 2. Injuries to internal organs (trunk level) (14%)

3. Fracture – limbs (13%) 3. Intracranial injury (13%)

As with hospitalisation, limb fractures were the most common fall-related injury seen in the emergency department (see Table 7). Dislocations, sprains and strains of head and neck level ligaments accounted for 16% of the transportation-related injuries. As with hospitalisation, poisoning accounted for the majority of suicide related emergency department visits. Open head and neck wounds accounted for a quarter of all violence-related injuries requiring a visit to the emergency department.



Table 7: Most Common Nature of Injury by Injury Mechanisms- Emergency Department Visits, Calgary Health Region Residents (Region 3 Boundaries), 2003/2004

Injury

Mechanism Most Common Nature of Injury

Falls 1. Fracture of limbs (37%) 2. Dislocation, sprain/strain of limb joints and ligaments (12%) 3. Open wound of head/neck (10%)

Transportation 1. Dislocation, sprain/strain of

head/neck level joints/ligaments (16%)

2. Fracture - limbs (16%) 3. Superficial injury of limbs (9%)

Suicide 1. Poisoning (78%) 2. Open wound of limbs (13%) 3. Open wound of head/neck (2%)

Violence 1. Open wound of head/neck (25%) 2. Superficial injury of head/neck (12%) 3. Fracture at head/neck level (10%)

Other Injuries – Unintentional Poisoning Other types of injury mechanisms make up a significant proportion of total injuries for both hospitalisation and emergency department visits (see Figures 5 & 6) however, these injuries are often relatively infrequent or unspecified. In an attempt to broaden the total injury picture covered by this report, unintentional poisoning as a cause of injury is explored. Injuries due to unintentional poisoning account for 13% of all injury-related hospitalisations and 10% of all injury-related emergency department visits. In terms of frequency then, poisoning has a similar impact on utilisation as do transportation-related injuries. While there does not appear to be a clear pattern of gender differences for poisoning-related hospitalisation (see Figure 20), there are age differences. Injury rates are lowest for the youngest age groups and show a steady increase over the life span.

Figure 20: Poisoning-Related Hospitalisations: Age and Gender Specific Utilisation Rate per 100,000 People, Calgary Health Region Residents (Region 3 Boundaries), 2003/2004

1810 10

16 16

31 31

59

49

81

20

4

14

2516

13

33

43

63 62

0102030405060708090

0-4 5-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 85+

Age Groups

Num

ber o

f Eve

nts

Female Male

As Figure 21 shows, poisoning-related emergency department visits also do not vary much between genders. Similar to hospitalisation, there are marked differences across the life span; however, the overall pattern is reversed. Poisoning-related emergency department visit rates are highest in the 0 to 4 and 15-24 year age groups and steadily decrease thereafter. Injury rates increase slightly beyond age 75.



Figure 21: Poisoning-Related Emergency Department Visits: Age and Gender Specific Utilisation Rate per 100,000 People, Calgary Health Region Residents (Region 3


173

502

166 184

311

672

161

337 317

197119

216281

162171233255

575

164

467

0

100

200

300

400

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700

800

0-4 5-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 85+

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Female Male

Unintentional poisonings that result in a hospital visit are most likely due to painkillers, hallucinogens, sedatives and the toxic effect of alcohol. Poisonings that are seen in the emergency department, however, are more likely to be due food poisoning, alcohol, painkillers, and hallucinogens. Workplace Injuries Males are much more likely than females to experience a workplace-related injury that results in hospitalisation (see Figure 22). There is less of an effect of age, however, particularly between the ages of 15 and 64. Males are also much more likely to visit the emergency department due to a workplace-related injury, but there is a different pattern for age. Injury rates are highest for younger workers (aged 15 to 34) and then steadily decrease until retirement is reached (see Figure 23). While inexperience may explain the higher rates in the younger age groups, the gender difference may be explained, in part, because men tend to be over-represented in higher hazard industry sectors9.

Figure 22: Workplace-Related Hospitalisations: Age and Gender Specific Utilisation Rate per 100,000 People, Calgary Health Region Residents (Region 3 Boundaries),

2003/2004

49

611 12

7

40

47 49

5751

14

0

10

20

30

40

50

60

15-24 25-34 35-44 45-54 55-64 65-74

Age Groups

Num

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f Eve

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Female Male

9 Human Resources and Employment (July, 2003). Occupational Injuries and Diseases in Alberta: 2002 Summary



Figure 23: Workplace-Related Emergency Department Visits: Age and Gender Specific Utilisation Rate per 100,000 People, Calgary Health Region Residents (Region 3


217 169 140 15183

13

1050 1061

746

537

343

51

0

200

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15-24 25-34 35-44 45-54 55-64 65-74

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Sport and Recreational Injuries Since April 2000, sport and recreational injuries treated at Alberta emergency departments have received a supplementary sport code. Although there are limitations associated with the use of these codes (see Appendix B), they represent an improvement in the surveillance of sport and recreational injuries over the use of ICD-10-CA codes alone. A list of the most common sport and recreational activities that resulted in a visit to Calgary Health Region emergency departments is presented in Table 8. The most common sport and recreational injuries are due to ice hockey, cycling and soccer. The specific injury sustained may have been due to any number of mechanisms (i.e., a fall-related injury, a transportation-related injury and so on). Regardless of specific activity, males account for 75% of the injuries and the majority of the injuries occur to those under 19 years of age. Table 8: Ten Most Common Sport and Recreational Activities Resulting in an

Emergency Department Visit, Calgary Health Region Residents (Region 3 Boundaries), 2003/2004

Ten Most Common Sport and Recreational Activities ED Visits % Ice hockey 1695 14% Cycling 1462 12% Soccer 1133 9% Snowboarding 801 7% Basketball 639 5% Baseball 569 5% Playground 552 5% Football 523 4% Skateboarding 481 4% Downhill skiing 342 3% All other sport and recreational injuries 3764 32% Total all sport and recreational injuries 11961 100%

1 The total number of emergency department visits was 61,178. 20% (11,961) of these visits were for injuries that received a supplementary sport and recreational code.



Without knowing how many people participate in each sport, it is difficult to determine how risky each sport is. Naturally, a sport that many region residents participate in will generate a higher number of injuries than a sport where there are fewer participants. So, it may be that there are more injuries due to hockey, cycling and soccer because they are the most popular sports and not necessarily because there is a greater chance of injury when participating in them. In order to calculate activity-specific rates (i.e., to determine the relative degree of risk involved in each activity), it would be necessary to track the number of participants and amount of participation in each of the activities. Once this information is available, it will be possible to target specific sports more accurately.

Injury Data Summary The death rate has increased somewhat from 2001 but dropped slightly from 2000. The potential years of life lost per death, on average, has followed a similar pattern across time. Injury deaths accounted for 7% of the total deaths in the region. Over the last three years, suicide has accounted for more than a third of all injury-related deaths. Overall, falls and transportation are the most common injury cause for both hospital and emergency department utilisation. Males are, for the most part, at higher risk of sustaining an injury than are females, particularly in the workplace and as victims of violence. With regards to age, there is often a substantial increase in injuries between the ages of 15 and 24, a decline though middle ages and a subsequent increase in older age groups. There are, however, a number of exceptions to this overall trend. With respect to gender, females have a greater risk than males for both suicide-related hospitalisation and emergency department utilisation, particularly in the 15-24 year age group. Females, between the ages of 0-4 are also at greater risk for a violence-related injury that may result in either hospitalisation or an emergency department visit. With regards to age, fall-related injuries resulting in hospitalisation remain relatively unchanged throughout most of the life span but increase quite dramatically beyond age 65, particularly for females. Emergency department rates are higher in the young, decline through young adulthood and middle age and then increase in older age groups, again particularly for females. Many contributing factors have been identified that explain this gap10. There is also a marked contrast in pattern for hospitalisation and emergency department rates for poisoning. Poisoning-related hospitalisations increase over the life span, while emergency department rates for poisoning are higher in younger ages and then start to decrease over the life span.

10 Calgary Health Region (2003). A Framework for the Prevention of Falls and Fall Injuries in Older Adults: A Shared Responsibility.



Injury Prevention and Control Services Activity Highlights Injury Prevention and Control Services activity is organised around key objectives which are linked to both priority injury issues affecting the population and to identify risk groups. The objectives also reflect health promotion outcomes that are necessary to advance the overall goal of reducing the frequency and severity of injuries in the Calgary region. A common business plan is developed and implemented across the service team, with the majority of strategies involving collaboration with a number of regional health authority and community partners. The following section overviews selected activity highlights grouped by business plan theme.

1. Injury Data

Efforts to continually improve injury surveillance, data collection and data analysis are ongoing at the regional, provincial and national levels. For example, in early 2004 Injury Prevention and Control Services produced a detailed report on transportation-related injuries in the Calgary Health Region for the period 1997/98 to 2002/03. It looks at emergency department visits and hospitalisations, as well as deaths overall, and provides a more detailed analysis for three modes of transportation: motor vehicle, pedestrian and pedal. Staffs on the team who are dedicated to injury data collection and review have continued to build local capacity to obtain, manipulate, analyse and report injury data in a timely and focused manner. This has been achieved through structured interactions with the regional Quality Improvement and Health Information group to facilitate the direct provision of raw data. This data can then be accessed in a timely way to address specific injury data questions and requests that the team receives from internal and external sources. In addition to establishing a process for ongoing receipt of regional utilisation data, historical utilisation data has also been received and is part of the larger data management system which allows trends in injury data indicators and measures to be tracked over time.

2. Creating Environments to Promote Risk Management The Calgary Injury Prevention Coalition (CIPC) is hosted by the Injury Prevention and Control Services team and has a history of over ten years of facilitating collaborative injury prevention projects and initiatives in the Calgary region. As part of this host role, Injury Prevention and Control Services produces quarterly Coalition newsletters each year which profile activities of various Coalition member groups and communicate important events and issues. During 2003/2004, the Coalition also finalised work on six Coalition position statements on key injury prevention issues. These position statements reflect several months of collaborative, consensus building activity to arrive at key messages that the various member organisations can publicly support and promote. A CIPC Synopsis document was also produced which updates an original document and overviews the history and accomplishments of the coalition since it was founded in 1992. The CIPC annual membership event focused on traffic safety and a one day workshop was held with over 100 participants in attendance. A key area of focus for Injury Prevention and Control Services is the promotion of smart risk messages and strategies which support skill development and decision making by youth. The smartgrad Program was launched in 2000 and continues to grow and develop as focal point for engaging youth in injury prevention activity. Public health nurses working in high schools are supported with training and resources to enable risk management activities at the local school level. Evaluation of the program is ongoing and each year the feedback from the field is incorporated to improve the program. Smart risk messages and activities are also supported through linkages with groups such as Canada Olympic Park and Shaw Millenium Skateboard Park.



Wherever possible, opportunities to connect injury prevention and risk management concepts with the programs and activities of the community partners are maximised. The Calgary Health Region, Injury Prevention and Control Services is also actively involved with the Safer Calgary Initiative hosted by the City of Calgary. A number of projects have been undertaken since the city received national and international designations as a safe community in the spring of 2003. Over the past year, a comprehensive public survey of perceptions of safety has been completed which will help to guide future directions and priorities for safety promotion at the individual, family and community level. A Safety in the Home newsletter has also been produced which serves as a marketing and communication tool profiling key injury and safety issues that residents can take action on for themselves and their families.

3. Capacity Building for Injury Prevention A major portion of the work of Injury Prevention and Control Services focuses on development and distribution of resource materials and training for staff groups within the Calgary Health Region and with key community partners. The Injury Prevention Resource Manual, developed last year, has been widely disseminated across the region, including provision of copies for each Health Link call station. The manual has also been posted on the website11. A specific training session for public health nurses was developed using a “train the trainer” model whereby injury prevention representatives were assisted to provide orientation to colleagues regarding use of the manual. A program, which was piloted last year in three community health centres, has been expanded this past year to include all community health centres. This expansion was based on the positive results of a comprehensive evaluation of the initiative and keen interest from the front line practitioners. A Million Messages is a standardised approach to the delivery of priority injury prevention messages which are matched to the developmental stages of growing children. To support practitioners, a self-directed learning module on the program has been developed and is available to staff on the website. Additional practitioner groups such as physicians and community care providers are also being considered for further implementation of A Million Messages.

4. Intentional Injury Prevention A campaign plan for the prevention of Shaken Baby Syndrome (SBS) in Calgary and area was completed over the past year and involved several regional program areas as well as key community partners such as the Calgary Police Service and Child and Family Services. The plan outlines a series of strategies to support professional awareness of the issue to better enable practitioners to work effectively with families in the community. In addition to completion of the plan, two key resources were also produced. The first is a crying brochure entitled When your baby can’t stop crying which serves to address one of the major triggers for shaking episodes. The second is a professional resource guide which overviews the issue of SBS and provides additional information for practitioners. The campaign plan has received external funding which will enable full implementation over the coming year. Work on intentional injuries, especially in the area of suicide, is shared with the Mental Health Promotion area of Healthy Living. Key outputs over the past year include Hope and Healing, a guide for survivors of suicide and initiation of suicide postvention protocol development for regional programs and services. Partnership work with the Centre for Suicide Prevention is ongoing, including support to the development of a youth suicide prevention website.

11 All resources and reports produced by Injury Prevention and Control Services are available on the regional

website under Injury Prevention.



5. Fall Prevention The previously completed regional framework for the prevention of falls and fall injuries in older adults received full endorsement from senior management this year and the implementation planning has been initiated. The document has been widely distributed and regional contacts for the committees have been identified. The Calgary Injury Prevention Coalition, Older Adult Falls Prevention Committee, continues to advance fall prevention activities at the community level. Over the past year a fall prevention display for community events was produced and an exercise lending library was established. Funding is being sought to expand the provision of community based fall prevention and exercise programs. The CIPC Playground Safety Committee has actively promoted playground safety issues for almost a decade. The committee has wide participation from playground equipment suppliers, health, school boards and social service agencies. Fall and fall injury prevention are a major aspect of the playground safety work through initiatives such as the promotion of safe playground surfacing and equipment and educational activities for staff working with children in a variety of settings. A major playground safety awareness event for childcare centres was initiated this year.

6. Traffic Safety Traffic safety issues continue to be a major focus of the work in Injury Prevention and Control Services due to the magnitude of the problem in the Calgary region. The importance of booster seat use for children 4 to 8 years of age is a new priority. Studies have documented the increased risk of injury for small passengers in a collision when they are restrained by an adult seatbelt only instead of a booster seat which allows the seatbelt to fit them properly. Local surveys of parents have also documented that a significant number of parents believe that their children are too big for a booster seat when, in fact, they are not. A grant was received from the Alberta Traffic Safety Foundation to initiate a booster seat awareness campaign for parents and professionals. Pedestrian safety has also emerged as a priority traffic safety issue over the past year. Working with a number of community partners, the Calgary Health Region is participating in a pedestrian safety campaign which aims to address the shared responsibility of both motorists and pedestrians for ensuring safety. The Look Out for Each Other campaign has utilised signage at intersections, and advertising on radio and buses. Additional campaign strategies are under development including the possibility of working with private landowners who oversee operations at major sites such as shopping malls and the airport. Data has indicated that a significant number of pedestrian injury events occur in these locations. Other traffic safety initiatives completed this year included facilitation of a local forum to provide input to the Traffic Collision Fatality and Injury Reduction Report initiated by the Alberta Transportation Minister, which included a direct consultation with the report author. Road safety was also the theme of World Health Day, a yearly initiative of the World Health Organisation. Collaborative public awareness activities were undertaken with key traffic safety partners to mark this day including a major media event in the foyer of city hall to highlight the burden of traffic safety as a public health issue.



Recommendations and Alignment with Provincial Directions for Injury Control

Over the past year there have been two significant developments which will help to shape the direction of injury prevention work at the regional and provincial levels. The first development was the release of the Framework for a Healthy Alberta (Alberta Health and Wellness, 2003) which provides direction for the Government of Alberta to promote health and prevent disease and injury. The Framework sets targets to 2012 and outlines government strategies for two broad health outcomes: improving healthy behaviours and reducing the incidence of chronic disease among Albertans. One of the objectives for the first outcome is that more Albertans take steps to prevent injuries (Objective 1.5). Direction has been given from both provincial and senior portfolio management levels of the Calgary Health Region that regional level targets must be established in the areas identified in the document. These regional targets must align with the provincial indicators in the Framework and also meet region specific requirements. As a comprehensive approach to injury control in the province, the Framework mandates the development of a provincial injury control strategy. This provincial injury control strategy is the second major development that has occurred over the past year and is the result of the combined efforts of injury prevention stakeholders across the province. The Alberta Injury Control Strategy (AICS) has been developed but not yet implemented. It is intended to guide stakeholders in the development of individual, organisational and cross jurisdictional business plans and to enable stakeholders to collaborate on broader initiatives related to their mandate. The AICS includes a diverse range of indicators including process, impact and outcome measures. Injury Prevention and Control Services has acted upon the direction to align regional work in injury prevention with the Framework and to make specific recommendations on appropriate targets for the Calgary Health Region. This work is reflected in Table 9. The table presents each injury-specific Framework indicator and target as specified by Alberta Health and Wellness on the left side of the table and then presents what regional data is currently available on that target in the centre of the table. On the right side of the table, the proposed draft regional targets are presented and it is noted where resources are required for measurement and program development. Additional regional indicators and targets have been proposed which augment those in the provincial document. The new indicators, recommended for the Calgary Health Region, are presented as shaded sections of the table and there is no information on the left side of the table for these. Rationale for inclusion of the additional targets is provided and generally reflects recommendations contained in the AICS and the data-led priorities of the Injury Prevention and Control Services business plan. The targets and objectives specified in the Framework for a Healthy Alberta and Alberta Injury Control Strategy, including the additional recommended targets for the Calgary Health Region, provides valuable templates for future action and an organising structure to report progress on injury reduction in subsequent years. This will, however, require the coordinated efforts of a number of partners beyond the health sector in order to achieve the outcomes that have been set. Through the variety of activities and initiatives that Injury Prevention and Control Services facilitate, we will continue to demonstrate leadership in the core areas of our mandate and to advocate for others to take action within their roles.


Table 9: Framework for a Healthy Alberta1: Objective 1.5: More Albertans take steps to prevent injury Framework for A Healthy Alberta (FHA): Targets to 2012 Draft Regional Targets to 2012

Indicator Baseline Target

Where the Region Stands Now (Based on most current regional

data)2 Indicator Baseline Target

Rural Target: The proportion of Calgary Health Region residents in rural areas who use seatbelts in rural areas.

77%

95%

Measurement: Rural Seatbelt Survey (note if this survey is not repeated, then other means

of monitoring seatbelt use will be required) Resources Required: Support of the Rural Seat Belt Survey through participation in AORP Additional resources required to develop and implement targeted

programming in collaboration with traffic safety partners Urban Target: Option 1: Use Framework target (this target

is population-based but not very precise due to lack of data collection at the regional level).

Option 2: Establish regional baseline to

accurately set a regional target and monitor change.

Option 1: Framework Baseline (89.3%) Option 2: To be established

Option 1: Framework Target (95%) Option 2: Percentage increase to be determined (after baseline established)

The proportion of Albertans who use seat belts. - Source: Transport Canada

Annual National Seat Belt Survey

Rural: 69.2% Urban: 89.3%

95% throughout the province

Rural: 77% of drivers and right front seat

passengers of light duty vehicles use seat belts (Source: 2001 Rural Seat Belt Survey*)

2004 data should be available November, 2004

Urban: No regional data

*Region 4 boundaries

Measurement: Option 1: Wait for next Transport Canada Survey to monitor change Option 2: Design and implement regional survey to monitor change

Resources Required: Continued participation in AORP Additional resources required to establish baseline Additional resources required to develop and implement targeted

programming in collaboration with traffic safety partners Additional resources required to monitor change


Framework for A Healthy Alberta (FHA): Targets to 2012 Draft Regional Targets to 2012




The proportion of children who travel in properly used, approved child safety seats within the Calgary Health Region.

To be established

Percentage increase to be determined (after baseline established)

The proportion of children who travel in properly used, approved child safety seats. - Source: Think, Think Again

Year Five Final Report

70% 95% No regional baseline

Rationale: Since the baseline used in the Framework target is not population-based nor

are the criteria for proper car seat use specified, it is suggested that a more valid baseline be adopted such as the baseline that will be established by the proposed AORP study Child Restraint Use in Rural and Urban Areas of Alberta. This study, in its first phase, proposes to estimate the prevalence of proper restraint use in those under age 16 in both rural and urban areas of the province.

Measurement: Through initial and additional phases of proposed AORP study

Resources Required: Continued participation in AORP and support of study Additional resources required for targeted programming in collaboration with

traffic safety partners Additional indicators/targets proposed: Based on the Injury Prevention and Control Services Business Plan 2004-2005 (see also AICS, June 2003).

Bicycle helmet use in children, adolescents and adults living in the Calgary Health Region.

To be established

Percentage increase to be determined (after baseline established)

For Calgary, Cochrane, Airdrie and Okotoks: Children (0-12): 87% Adolescents (13-17): 40% Adults (18+): 55% (Source: Bicycle Helmets: Observational Study Summary, 2001*) *Note that the survey does not cover all of the region (Region 4 boundaries or Region 3 boundaries)

Rationale: Since the baseline available from the Bicycle Helmet Observational Study is

not population-based and only represents a portion of the region, it is suggested that a more valid baseline be established, so that accurate regional targets can be set and progress monitored.

Measurement: Potential bike helmet study (population-based)

Resources Required: Resources required to establish baseline through a population-based study Additional resources required to develop and implement targeted

programming with traffic safety partners






The rate of ice hockey-related injuries to minor hockey league players in the Calgary Minor Hockey League.

To be established

Percentage reduction in rate to be determined (after baseline established)

No regional data

Rationale: Ice hockey is one of the leading sports and recreational activities causing injury. Measurement: Minor Hockey League Injury Surveillance Project (University of Calgary

Kinesiology Department) While this project does not focus on the whole health region, it will provide a

proxy measure of regional hockey injuries and may provide a sound methodology that could be implemented at a regional level

Resources Required: Continued participation in Youth Ice Hockey Injury Working Group Additional resources will be required to implement this project on a regional

scale Mortality rate due to motor vehicle collisions - Source: Alberta Vital

Statistics Death Registration Files, Produced by Alberta Health & Wellness

10.7 per 100,000 people*

5 per 100,000 people

2002 mortality rate due to motor vehicles*: 5.5 per 100,000 people (Source: Data supplied by QIHI) *ICD-10-CA V200 – V799, V830-V899; Region 4 boundaries

Mortality rate due to motor vehicles. 5.5 per 100,000 people


Additional indicators/targets proposed: Consistently using morbidity and mortality will provide a more accurate reflection of the burden of injury than the use of either alone (see also AICS, June 2003).

2003-04 hospitalisation rate due to motor vehicles*: 51 per 100,000 people (Source: Data supplied by QIHI) *ICD-10-CA V200-V799, V830-V8698; Region 3 boundaries

The rate of people hospitalised due to motor vehicles.








2003-04 emergency department visit rate due to motor vehicles*: 373 per 100,000 people (Source: Data supplied by QIHI) *ICD-10-CA V200-V799, V830-V8698; Region 3 boundaries

The rate of people who visit the emergency department due to motor vehicles.



Mortality rate due to suicide. - Source: Alberta Vital

Statistics Death Registration Files, Produced by Alberta Health & Wellness

15.2 per 100,000 people

12.3 per 100,000 people

2002 mortality rate due to suicide*: 13 per 100,000 people (Source: Data supplied by QIHI) *ICD-10-CA X60-X84; Region 4 boundaries

Mortality rate due to suicide. 13 per 100,000 people

12.3 per 100,000 people

Additional indicators/targets proposed: Consistently using morbidity and mortality will provide a more accurate reflection of the burden of injury than the use of either alone (see also AICS, June 2003). 2003-04 hospitalisation rate due to

suicide-related injuries*: 45 per 100,000 people (Source: Data supplied by QIHI) *ICD-10-CA X60-X84; Region 3 boundaries

The rate of people hospitalised due to suicide-related injuries.



2003-04 emergency department visit rate due to suicide-related injuries*: 103 per 100,000 (Source: Data supplied by QIHI) *ICD-10-CA X60-X84; Region 3 boundaries

The rate of people who visit the emergency department due to suicide-related injuries.



The rate of people hospitalised due to falls. - Source: Alberta Health &

Wellness

366.8 per 100,000 people


2003-04 hospitalisation rate due to falls*: 287 per 100,000 people (Source: Data supplied by QIHI) *ICD-10-CA W00-W19; Region 3 boundaries

The rate of people hospitalised due to falls, from 287 to 258 per 100,000 people.








Additional indicators/targets proposed: Consistently using morbidity and mortality will provide a more accurate reflection of the burden of injury than the use of either alone. However, rates based on a small number of events tend to be unstable, therefore, no indicators or targets for mortality due to falls was included (see also AICS, June 2003). 2003-04 emergency department visit

rate due to falls*: 1636 per 100,000 people (Source: Data supplied by QIHI) *ICD-10-CA W00-W19; Region 3 boundaries

The rate of people who visit the emergency department due to falls.

1636 per 100,000 people

1309 per 100,000 people

2003-04 hospitalisation rate due to falls*: 1502 per 100,000 people, aged 65+ (Source: Data supplied by QIHI) *ICD-10-CA W00-W19; Region 3 boundaries

The rate of people aged 65+ hospitalised due to falls.

1502 per 100,000 people aged 65+


2003-04 emergency department visit rate due to falls*: 3437 per 100,000 people, aged 65+ (Source: Data supplied by QIHI) *ICD-10-CA W00-W19; Region 3 boundaries

The rate of people aged 65+ who visit the emergency department due to falls.



Lost time claims per 100 person years worked. - Source: Alberta Human

Resources and Employment Business Plan 2002-05

3.4 per 100 person years worked

2.0 per 100 person years worked

No regional data available The possibility of obtaining regional level data from Worker’s Compensation Board could be explored. A limitation of these data, however, is that current reporting is based on home office location of the employer rather than where the employee was injured. Other possibilities include monitoring the rate of people hospitalised and the rate of people who visit the emergency department due to workplace injuries (i.e., where there is WCB payment).

1 Framework for a Healthy Alberta (Alberta Health and Wellness, 2003). 2 All rates for 2003/2004 are based on 2003/2004 population projections as actual population data were not yet available. Rates will be updated once actual population figures are available.



Appendix A: Data Considerations

Injury Coding Changes ICD-10-CA codes were used to select cases for both the 2002/03 and 2003/04 reports, but there are differences between the two reports in how cases were classified to specific injury mechanisms. The 2002/03 Injury Prevention and Control Report presented injuries due to motor vehicle collisions whereas the current report uses a more inclusive category, which includes all transportation-related injuries or deaths (see Appendix B).

Regional Boundary Changes There was a change in regional boundaries as of April 2003. There are two main effects of this boundary change:

1. At present, the data includes utilisation of acute care facilities within the City of Calgary by any Region 3 residents (i.e., both urban and rural). The data represent the following facilities: Alberta Children’s Hospital, Foothills Medical Centre, Rockyview General Hospital, and Peter Lougheed Centre. Data for the utilisation of the following rural sites are not yet available: Canmore Hospital, Claresholm Hospital, High River Hospital, Banff Mineral Springs Hospital, Oilfields Hospital (Black Diamond), Strathmore Hospital, and Vulcan Health Centre. Utilisation rates will be affected, therefore, because some region residents will have sought medical attention at one of the excluded acute care facilities, yet the rates are calculated using the total population12. Utilisation data from rural acute care facilities should be available for the next reporting period.

. 2. Comparability to the injury data presented in the 2002/03 report is limited in this respect as rates

are calculated for a different geographical area. Direct comparisons should be limited to those rates that have been age-standardised for both populations.

The influence of the regional boundary change is not an issue for mortality as the data reported are all based on pre-April 2003 boundaries

Mortality Data Mortality data covers a different time period than the injury utilisation data. Mortality data is based on the calendar year 2002 while the utilisation data is based on the 2003/04 fiscal year. Since mortality data have been coded in ICD-10-CA since 2000, it is possible to compare the last three years of available data13.

Population Data This report uses projected population estimates for 2003/04 as actual population data were not yet available. Population at midyear is used to calculate utilisation rates. Midyear for the fiscal year is September and June for the calendar year. Midyear population is estimated from the March year-end population. See Appendix B for the formula used to calculate midyear population in this report.

12 Eighty-two percent of the Region’s population is urban and 18% is rural. 13 The 2001 mortality data have been revised; the total number of injury-related deaths is 320 compared to 304 as presented

in the 2002/03 report. As a result, the crude mortality rate and PYLL for 2001 presented in this report will also differ from last year’s report.



Sport and Recreational Injuries Sport and recreational injury codes are only assigned on the initial visit to regional emergency departments. These supplementary codes are not used for injuries that require hospitalisation, treated by community physicians, walk-in clinics or injuries that received no medical treatment. In addition, some of those who were injured would have gone straight onto a hospital ward, bypassing the emergency department. There is no established process to determine the completeness of the sports and recreation supplementary coding. The data presented, therefore, reflects those cases that were assigned a sports code and may not be representative of all sport and recreational injuries that are treated at the emergency department.

Other Data Considerations The report underestimates the total burden of injury. Data are presented only for the most serious of injuries – those resulting in an emergency department visit, hospitalisation or death. Data are not available for injuries that are presented at physicians’ offices and clinics or that are treated at home. It should be noted that the hospitalisation and emergency department data sets are not mutually exclusive. Visits to an emergency department may result in hospitalisation depending on the nature (and severity) of the injury and, therefore, will be considered both an emergency department visit and a hospital visit. Caution should be exercised when interpreting utilisation because the injury utilisation data are based on frequency of visits. As such, a large number of visits does not provide information about the severity of the injury. When population injury rates are calculated, it is assumed that each person is at equal risk of an injury, which may not necessarily be true. The result is that these rates generally underestimate the true injury rate for high risk individuals, and overestimate the true injury rate for low risk individuals. In addition, rates of utilisation and mortality that are derived from a small number of events should be used with caution (i.e., rates derived from a small number of events and small reference populations tend to result in highly unstable rates). Finally, data are subject to the limitations inherent in administrative data, which are routinely collected for purposes other than research.



Appendix B: Code and Data Definitions

Code Definitions Injury Mechanism

Injury Category ICD-10-CA Code Definitions All injuries V010-Y369, Y850-Y872, Y890-Y899

Transportation V010-V799, V810-V819, V830-V899

Falls W00-W19

Suicide X60-X84

Violence X85-Y09

Poisoning X40-X49

Other V800-V809, V820-829, V900-V99, W20-W74, W75-W84, W85-X39, X50-X59, Y10-Y369, Y850-Y872, Y890-Y899

Nature of Injury

Nature of Injury Category ICD-10-CA Code Definitions

Fracture – head/neck level S020 - S02901, S120 - S12901

Fracture – limbs S420 - S42901, S520 - S52901, S620 - S62801, S720 - S72901, S820 - S82901, S920 - S92901

Open wound of limbs S410 - S4181, S510 - S5191. S610 - S6191, S710 - S7181, S810 - S8191, S910 - S9172

Fracture - trunk level S220 - S22901, S320-S32801

Internal organs (trunk level) S260 - S27981, S360 - S37991

Intracranial injury S060 - S06991

Poisoning T360 - T659

Other/unspecified effects, certain early complications of T66 - T799



Data Definitions Midyear Population Calculations Population at midyear is used to calculate utilisation rates. Midyear for the fiscal year is September and June for the calendar year. Midyear population is estimated from the March year-end population. Midyear population is calculated as follows: September 2003 midyear estimate: 0.5*population at March 31, 2003 + 0.5*population at March 31, 2004

June 2003 midyear estimate: 0.75*population at March 31, 2003 + 0.25*population at March 31, 2004

Potential Years of Life Lost Calculations Potential years of life lost (PYLL) is an indicator of premature mortality. It represents the number of years not lived by an individual from age 0 who died before age 80. This indicator gives more importance to the causes of early death than those at old age.

Total PYLL is calculated as follows: Sum(80-age at death) Average PYLL is calculated as follows: Sum(80-age at death) #dying who are >80 years of age Crude Rates A crude rate is a summary measure that is unadjusted for differences within the population. It is based on a specific time period, usually one year. A crude utilisation rate, for either hospitalisation or emergency department visits, is calculated as follows: Total number of injury related visits in the population The total number of individuals in the population These rates provide some context by accounting for both the number of injury visits and overall population size as compared to a count of injury events alone. Crude rates do not, however, account for differences within specific segments of a population. A different picture may emerge by looking at specific segments of the population (e.g., gender or age). Category Specific Rates A category specific rate accounts for differences within particular segments of the population. An age and gender specific utilisation rate for either hospitalisation or emergency department visits is calculated as follows: The number of injury related visits in each gender-age segment of the population The number of individuals in the each gender-age segment of the population These rates are not confounded by either gender or age, that is, differences that may exist because of age or gender will not be obscured. As such, category specific rates provide a more detailed view of the pattern of utilisation in the population than a crude utilisation rate alone. Standardised (Adjusted) Rates Standardised or adjusted rates provide a summary value that removes the effect of the differences in population structure (e.g., age and/or gender) to allow for valid comparisons between different groups or the same group over time. The actual value of the adjusted rate is meaningless, however, since it has been statistically constructed based on the choice of a standard.



In the direct method of standardisation, adjusted rates are calculated by applying the category-specific rates observed in each of the populations to a single standard population. The standard population used for comparing the same groups over time is the last year of Alberta Health Registry data for the Calgary Health Region (March 2002/03) and, for comparing different regions, the standard used is the Alberta Health Registry provincial population (March 2002/03). An age standardised rate for each population being compared is calculated as follows: 1. Age-specific rate of age group x standard population of age group = standardised utilisation rate 100,000 (per age group) 2. Total (sum of standardized utilisation rates) = standard utilisation rate Total standard population The adjusted rate is a single summary rate that reflects the numbers of events that would have been expected if the populations being compared had had identical distributions of the characteristic of interest. Relative Utilisation Rates Relative utilisation rates for each gender-age segment are generated from the age group specific utilisation rate for each gender divided by the total population rate (i.e., without age or gender breakdown). The relative utilisation rate, therefore, describes the likelihood that someone in that gender-age category will be hospitalised or visit the emergency department with an injury, when compared to the entire population.



Appendix C: Absolute Utilisation The following section presents absolute hospital and emergency department utilisation (i.e., the number of hospital and emergency department visits) by age and gender. Rates are presented in the Injury Data sections.

All Injuries Figure C1: All Injury-Related Hospitalisations by Age and Gender, Calgary Health

Region Residents (Region 3 Boundaries), 2003/2004

80

292 303

570

445

92

258

682

569

624

522

310

232262

153

360336

254283

155

0

100

200

300

400

500

600

700

800

0-4 5-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 85+

Age Groups

Num

ber o

f Eve

nts

Female Male

Figure C2: All Injury-Related Emergency Department Visits by Age and Gender, Calgary Health Region Residents (Region 3 Boundaries), 2003/2004

11161403

979

2953

6157

8703

6466

5344

3526

1585

715365

2385

38734400

3298 29932544

1512

860

0

1000

2000

3000

4000

5000

6000

7000

8000

9000

10000

0-4* 5-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 85+

Age Groups

Num

ber o

f Eve

nts

Female Male*Gender missing for one case.

Fall-Related Injuries Figure C3: Fall-Related Hospitalisations by Age and Gender, Calgary Health


2957 58 69

167

232

472

397

30

106

146 148182

204

160134

194

126115

189

0

50

100

150

200

250

300

350

400

450

500

0-4 5-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 85+

Age Groups

Num

ber o

f Eve

nts

Female Male

Figure C4: Fall-Related Emergency Department Visits by Age and Gender, Calgary Health Region Residents (Region 3 Boundaries), 2003/2004

695 662

1012

780

1127

2275

1549

1028 1012897

400 445259

862777709889

1558

903

514

0

500

1000

1500

2000

2500

0-4 5-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 85+

Age Groups

Num

ber o

f Eve

nts

Female Male

Transportation-Related Injuries Figure C5: Transportation-Related Hospitalisations by Age and Gender,

Calgary Health Region Residents (Region 3 Boundaries), 2003/2004

4

26

61

41 42 44

2820 16

37

52

153

10290

83

34

18 1710

0

20

40

60

80

100

120

140

160

180

0-4 5-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 85+

Age Groups

Num

ber o

f Eve

nts

Female Male

Figure C6: Transportation-Related Emergency Department Visits by Age and Gender, Calgary Health Region Residents (Region 3 Boundaries), 2003/2004

65

15286 54

1184

695

959

784

566

409

8646

9

333348

478

629

315

144

0

200

400

600

800

1000

1200

0-4 5-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 85+

Age Groups

Num

ber o

f Eve

nts

Female Male



Suicide-Related Injuries Figure C7: Suicide-Related Hospitalisations by Age and Gender, Calgary Health


0

22

85

59 58

39

14

5 400

6

54 55

48

33

14

62 1

0

10

20

30

40

50

60

70

80

90

0-4 5-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 85+

Age Groups

Num

ber o

f Eve

nts

Female Male

Figure C8: Suicide-Related Emergency Department Visits by Age and Gender, Calgary Health Region Residents (Region 3 Boundaries), 2003/2004

0

37

247

166

132

87

2311 6 10

11

147

97 106

49

217 3 1

0

50

100

150

200

250

300

0-4 5-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 85+

Age Groups

Num

ber o

f Eve

nts

Female Male

Violence-Related Injuries

Figure C9: Violence-Related Hospitalisations by Age and Gender, Calgary Health Region Residents (Region 3 Boundaries), 2003/2004

82

11 1016

6 2 1 3 03 2

119

66

55

25

5 4 2 10

20

40

60

80

100

120

140

0-4 5-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 85+

Age Groups

Num

ber o

f Eve

nts

Female Male

Figure C10: Violence-Related Emergency Department Visits by Age and Gender, Calgary Health Region Residents (Region 3 Boundaries), 2003/2004

21 36 6625 6 9 212

64

947

486

321

131

38 10 2 4

136178

281

0

100

200

300

400

500

600

700

800

900

1000

0-4 5-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 85+

Age Groups

Num

ber o

f Eve

nts

Female Male

Poisoning-Related Injuries

Figure C11: Poisoning-Related Hospitalisations by Age and Gender, Calgary Health Region Residents (Region 3 Boundaries), 2003/2004

67

8

1416

26

15

18

10

67

3

11

22

16

11

16

12

9

2

0

5

10

15

20

25

30

0-4 5-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 85+

Age Groups

Num

ber o

f Eve

nts

Female Male

Figure C12: Poisoning-Related Emergency Department Visits by Age and Gender, Calgary Health Region Residents (Region 3 Boundaries), 2003/2004

191

125

391

8056

33 23

233

123

374

299 312

173

80

33 319

145

230226

0

50

100

150

200

250

300

350

400

450

0-4 5-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 85+

Age Groups

6

Female Male



Workplace-Related Injuries Figure C13: Workplace-Related Hospitalisations by Age and Gender, Calgary

Health Region Residents (Region 3 Boundaries), 2003/2004

0 03

86

96

20 00 0

32

42

4850

25

40 0

0

10

20

30

40

50

60

0-4 5-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 85+

Age Groups

Num

ber o

f Eve

nts

Female Male

Figure C14: Workplace-Related Emergency Department Visits by Age and Gender, Calgary Health Region Residents (Region 3 Boundaries), 2003/2004

0 140

4 0 00 2

840

942

735

472

167

14 1 0

128138150169

0100200300400500600700800900

1000

0-4 5-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 85+

Age Groups

Num

ber o

f Eve

nts

Female Male

Appendices

♦Appendix A: Trauma Research Publications ♦Appendix B: Trauma Research Funding Summary April 1, 2003 to March 31, 2004


Appendix A 150

TRAUMA RESEARCH PUBLICATIONS (2003-2004) Appendix A • Buckley R, Dooley P. Bilateral Calcaneal Fractures: Foot and Ankle International, Volume 25, page 47-52,

2004 • Buckley R, Tough S. Displaced Intra articular calcaneal fractures: JAOS, Volume 12, page 172-178, 2004 • Buckley R, Puloski S, Powell J. Rotational Malalignment of the Tibia following Reamed IM Nails, JOT,

Volume 18, pages 397-402, 2004 • Buckley R, O’Brien J. Personal Gait Satisfaction after Displaced Intra Articular Calcaneal Fracture: Foot and

Ankle Internation, Volume 25, page 657-665, 2004 • Kingwell S, Buckley R. The Association Between Subtalar Joint Motion and Outcome Satisfaction in Patients

with Displaced Intra Articular Calcaneal Fractures: Foot and Ankle International, Volume 25, pages 666-673, 2004

• van Tetering E, Buckley R. Functional Outcomes (SF-36) of Patients with Displaced Calcaneal Fractures Compared to SF-36 normative data: Foot and Ankle International, Volume 25, page 733-738, 2004

• Barla J, Buckley R. Displaced Intra Articular Calcaneal Fractures - Long Term Outcome in Women: Foot and Ankle International, Volume 25, page 853-856, 2004

• Kirkpatrick AW, Sirois M, Laupland KB, Liu D, Rowan K, Ball CG, Hameed M, Brown R, Simons, R, Dulchawsky SA, Nicolaou S. Hand-Held Thoracic Sonography for Detecting Traumatic Pneumothoraces: Extended Focused Assessment with Sonography for Trauma (EFAST). Journal of Trauma 2004; 57:288.

• Kirkpatrick AW, Sirois M, Ball CG, Laupland KB, Goldstein L, Hameed M, Brown DR, Simons RK, Kortbeek J, Dulchawsky S, Boulanger BB. The Hand-Held Ultrasound Examination for Penetrating Abdominal Trauma. Am J Surg 2004; 187:660-665.

• Kirkpatrick AW, Sirois M, Goldstein L, Dulchavsky SA, Brown DR, Cunningham J, Liu D, Simons RK. Effectiveness of the Hand-Held FAST Exam for Blunt Abdomina Trauma. Can J Surg 2004 (in press).

• Laupland KB, Gregson DB, Kirkpatrick AW, Kortbeek JB, Zygun DA, Findlay C, Hameed SM. Bloodstream Infection Complicating Trauma. Clin Ivest Med 2004;27:253-258.

• McPherson S, Plant J, Juszwishin K, Kortbeek JB et al. The Pretransport Index, A Prospective Validation Abstract. Air Med J (United States), Sep-Oct 2004, 23(5) p30-1.

• Dunham MB, Zygun D, Kortbeek JB, Petrasek P, Karmy-Jones R, Moore RD. Endovascular Stent Grafts for Acute Blunt Aortic Injury. J Trauma 2004 Jun;56(6):1173-8.

• MacKenzie S, Kortbeek JB, Mulloy R, Hameed SM. Recent Experiences with Multidisciplinary Approach to Complex Hepatic Trauma. Injury 2004 Sep;35(9):869-77.

• Widder S, Doig C, Burrowes P, Larsen G, Hurlbert RJ, Kortbeek JB. Prospective Evaluation of Computed Tomographic Scanning for the Spinal Clearance of Obtunded Trauma Patients: Preliminary Results 2003

Abstracts • Sirois M, Kirkpatrick AW, Goldstein L, Dulchavsky SA, Brown DR, Cunningham J, Liu D, Simons RK.

Effectiveness of the Hand-Held FAST Exam for Blunt Abdominal Trauma [abstr]. J Trauma 2004;56:217. • Brown DRG, Simons RK, Kirkpatrick AW. The Introduction of a “Civilian Facility Based” Military Trauma

Training Program Improves Canadian Forces Physician Assistants Confidence in their Knowledge and Skills [abstr]. J Trauma 2004;56:217

• Kirkpatrick AW, Ball CG, McBeth P, Dawson D, Campbell M, Jones J, Hamilton DR, Dulchavsky S, and Holcomb J. Extraterrestrial Haemorrhage Control: Terrestrial Developments in Technique, Technology, and Philosophy with Applicability to Traumatic Haemorrhage in Space [abstr]. Aviat Space Environ Med 2004;Vol.75:B68.

• Kirkpatrick AW, Breeck K, Wong J, Hamilton DR, Dulchavsky S, Sargsyan AE, Betzner M, Sawadsky B, and McDonnel M. The Potential of Hand-Held Trauma Sonography in the Aeromedical Transport of the Traumatized Victim. [abstr]. Aviat Space Environ Med 2004; Vol.75:B50

• Karmali S, Laupland KB, Findlay C, Harrop R, Kortbeek JB, Kirkpatrick AW, Hameed SM. Epidemiology of Severe Trauma among Treaty Status First Nations in the Calgary Health Region. [abstr] J Trauma 2004;57:463.

• Schneidereit NP, Simons R, Nicolaou S, Brown DR, Kirkpatrick AW, Redekop G, McKevitt E, Germann E. Utility of Screening for Blunt Vascular Neck Injuries with Computed Tomography Angiography. (abstr) J Trauma 2004;57:463.

• Garraway N, Brown DR, Nash D, Kirkpatrick AW, Schneidereit N, Van Heest R, Hwang H, Simons RK. Active Internal Re-warming Utilizing a Centrifugal Pump and Health Exchanger Following Hemorrhagic Shock, Surgical Trauma and Hypothermia in a Porcine Model. [abstr] J Trauma 2004;57:462.


Appendix A 151

• Widder S, Knox L, Hurlbert RJ, Doig C, Burrowes P, Larsen G, Kortbeek JB. Prospetive Evaluation of CT Scanning in the C-Spine Clearance of Obtunded Blunt Trauma Patients. J Trauma Jan 2004 56 (1) 221.

• Dunham MB, Zygun D, Kortbeek J, Karmy-Jones R, Moore R. Endovascular Stent Grafting for Blunt Aortic Injury. J Trauma Jan 2004 56 (1) 221.

Chapters Hameed SM, Sirounis D, Sepsis and septic shock; Parkhurst Exchange 2004; in press

Hameed SM, Kortbeek JB; Chest Trauma; Current Orthopedics 2003

Cohn SM, Hameed SM, Lopez PP, Pizano LR, Whinney RR; Abdominal Trauma; Intensive Care Medicine fifth edition 2003; Irwin RS Rippe JM eds; 1807-15.


Appendix B 152

TRAUMA RESEARCH FUNDING SUMMARY (2002/2003) APPENDIX B Dept - EMS: Emergency Medical Services; OS: Orthopaedic Surgery; CC: Critical Care; EM: Emergency Medicine; GS: General Surgery; CH: Community Health Sciences Dept Principal

Investigator Co-investigators

Title Funding Source Time Period Start/End

Grant amount in dollars ($)

EMS Anton, Andy Stiell, Ian and Vaillencourt, Christian

Pre-hospital Validation of the Canadian C-spine Rule

Calgary EMS July 1 2003 - July 1 2006

N/A

OS Buckley, Richard

McCormack, Bob, Royal Columbian Hospital, Vancouver

Prospective Randomized Trial: Prophylaxis of Deep Vein Thrombosis in Patients with Fractures of the Lower Extremity Distal to the Knee

Pfizer 2001 - 2006 $330,000.00

OS Buckley, Richard

Johnston, Kelly Prospective Randomized Trial for Sanders IV Calcaneal Fractures: Operative Reduction versus Primary Subtalar Fusion

OTA 2004 - 2007 $25,000.00

OS Buckley, Richard

Catherine Hui, Ian Jorgensen

Retrospective Review – Instance of Femoral Nail Removal after Femoral Fracture or Subtrochanteric Fracture

Internally funded Jan/02 - Jan/04 $1,000

OS Weber, Don Buckley, Richard Prospective Study Examining the Effect of Timing to Definitive Treatment on the Rates of Non-union and Infection in Open Fractures

Zimmer Canada June 03 - Dec 2005 $10,000.00

OS Mckee, Mike Buckley, Richard Prospective Study: Operative versus Non-Operative Treatment of Clavicular Fractures

AO Jan 03 - Dec 2004 $2,000.00

OS Buckley, Richard

Leighton, Ross Prospective Randomized Trial: Operative Fixation of Calcaneal Fractures with and without Alpha BSM

Depuy June 02 - Dec 2004 $30,000.00

OS Buckley, Richard

Bitting, Seth Osteosynthesis of Fractures of the Patella: Suture versus wire

Hip Hip Hooray Jan 00 - Dec 2005 $1,500.00

OS Buckley, Richard

Ross Leighton αBSM in Calcaneal Fractures Depuy Apr/01 - $10,000

OS Buckley, Richard

Jeremy Reed, Vaughan Bowen, Carmen Brauer

A Prospective Study of Distal Radial Fractures, Closed Reduction Percutaneous Pinning vs. Open Reduction and Plating

Internally funded Oct/01 - Oct/03 $1,200

EM Nijssen-Jordan Cheri

Development of a Decision rule for Ordering a CT scan in Children with Minor Head Injury

Alberta Children’s Hospital Foundation

1998 - 2003 $34,000

EM Nijssen-Jordan Cheri

Development of a Decision rule for Ordering a CT scan in Children with Minor Head Injury

CIHR 2001 - $145,845

TS Kortbeek, John

Mcpherson S, Plant J, Juszwishin K, Doig et al.

The Pretransport index, a Prospective Validation AB Health 2002 - 2004 $20,000


Appendix B 153

Dept Principal Investigator

Co-investigators

Title Funding Source Time Period Start/End

Grant amount in dollars ($)

TS Kortbeek, John

Widder S, Knox L, Hurlbert RJ, Doig C, Burrowes P, Larsen G

Prospective Evaluation of CT Scanning in the C-spine Clearance of Obtunded Blunt Trauma Patients. J Trauma Jan 2004 56 (1) 221

Calgary Health Trust 2001 - 2004 $2,500

TS Hameed, Sayed Morad

Kortbeek J, Karmali S, Laupland KB, Harrop R, Findlay C, Dyer D, Kirkpatrick A, Mulloy R, Winston B, Crowshoe L,

Epidemiology of severe trauma in treaty status Aboriginal Canadians: A population-based study

CHAPS 2002 - 2004 $3,168.00

TS Hameed, Sayed Morad

Kortbeek J Double blind placebo controlled trial using rFVIIa (Niastase) in the treatment of bleeding in severe trauma injury

Novo Nordisk Feb - Oct 2003 -

TS Kirkpatrick, Andrew

Brown DR, Nicolaou S, Collistro R, Garaway N.

ASRIP (Alberta Science and Research Investment Program) - “Project neuroArm: MR compatible image guided robot

2004 -

CC Doig, Chip Impact of multiple organ dysfunction syndrome in the intensive care unit on quality of life and costs

Health Services Fund (AHFMR)

Jul/01 - Aug/03 $100,000

CC Doig, Chip Multiple Organ Dysfunction Syndrome, Quality of Life, and Costs in the ICU

CRHA 7th Annual Funding Competition

Jun/01 - Jun/03 $20,000

CC Easton, Paul Kortbeek J Respiratory muscle control with ascending spinal paralysis

Canadian Institutes of Health Research

2001 - 2004 $274,104

CH Thurston, Wilfreda

Leslie Tutty Evaluation of the 8th & 8th Protocol for Domestic Violence Screening

Calgary Health Region

May/02 - Dec/03 $10,868

CC Winston, Brent

Intensive Care Research Program Alberta Innovation and Science Award

Jul/02 - Feb/05 $165,000

CC Winston, Brent

Macrophage-derived growth factors in ARDS Alberta Lung Association

Sep/01 - Jun/03 $50,000

CC Winston, Brent

Regulation of factor B in septic shock: Importance of the alternative pathway of complement activation

Heath and Stroke Foundation of Canada

Jul/02 - Jun/05 $156,000

CC Winston, Brent

Use of NK-KB inhibition to attenuate murine scald-burn wound inflammation

University of Calgary Research Grant Award

Sep/02 - Aug/04 $6,000

CC Winston, Brent

The local and systemic effects of adenoviral-mediated BF gene transfer in mice

Canadian Intensive Care Foundation

Sep/02 - Aug/03 $25,500

Total funds dedicated and received to support trauma related research: $1,835,185.00

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