Regional Trauma Services

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					Regional
Trauma
Services
    ANNUAL REPORT

 April 1, 2007 - March 31, 2008
Regional
Trauma
Services
ANNUAL REPORT

April 1, 2007 - March 31, 2008
Regional Trauma Services                                                           2007/2008




                            Special Acknowledgement To:

Many professionals have made significant contributions over the year to the information,
data, and documents contained in this report.

Dr. Ian Anderson              Trauma Surgeon
Ms. Dianne Ashman             Regional Trauma Services Data Entry Clerk
Ms. Dianne Dyer               Regional Trauma Services Manager
Ms. Christi Findlay           Regional Trauma Services Data Analyst
Ms. Natalie Hohman            Regional Trauma Services Administrative Assistant
Dr. Vincent Grant             Pediatric Trauma Medical Director
Dr. Andrew Kirkpatrick        Regional Trauma Services Medical Director
Ms. Leanne Kmet               Regional Trauma Research Coordinator
Dr. Rohan Lall                Trauma Surgeon
Ms. Joyce Mammel              Orthopedic Trauma Clinical Nurse Specialist
Ms. Barbara Matiakis          Regional Trauma Services Nurse Clinician Specialist
Ms. Sherry MacGillivray       Regional Pediatric Trauma Coordinator
Ms. Michelle Mercado          Regional Trauma Services Data Analyst
Ms. Kimberly Musselwhite      Regional Trauma Services Manager
Ms. Jennifer Perez            Regional Trauma Services Data Analyst
Ms. Maria Vivas               Regional Trauma Services Data Analyst
Ms. Clara Yee                 Regional Trauma Services Data Analyst
Ms. Desiree Young             Regional Trauma Services Data Analyst


Note:
•  The author(s) of external submissions representing other departments or
   organizations will be specifically acknowledged on the report as per their direction.
Regional Trauma Services                                                                                                           2007/2008




                                       Calgary Health Region
                          Annual Regional Trauma Services Report 2007-2008


                                                         Table of Contents


Organization Structure................................................................................................................. i

Vision, Mission, Values, Roles .................................................................................................... ii

Medical Director’s Message ........................................................................................................ iii

Executive Summary..................................................................................................................... 1

Regional Trauma Services Activities ........................................................................................... 4

Regional Trauma & Injury Statistics Summary............................................................................ 15

Major Trauma Statistics & Outcome Data: Foothills Medical Centre .......................................... 18

Performance Indicators: Foothills Medical Centre...................................................................... 35

ACH Pediatric Trauma Program Report …………………………………………………………….. 56

Trauma Statistics & Performance/Outcome Data: Peter Lougheed Centre............................... 113

Trauma Statistics & Performance/Outcome Data: Rockyview General Hospital…………………124

An Imperative for Injury Prevention ............................................................................................. 135

Shock Trauma Air Rescue Society (STARS) Report .................................................................. 143

Calgary Firefighters Burn Treatment Centre Report ................................................................... 150

Tertiary Neurorehabilitation Program Reports
        Traumatic Brain Injury Population...................................................................................... 157
        Traumatic Spinal Cord Injury Population ........................................................................... 163

Appendices
     Appendix A: Trauma Research Publications .................................................................... 167
     Appendix B: Trauma Research Funding Summary .......................................................... 171
     Appendix C: Profile of Injuries in the Calgary Health Region Report ............................... 172
Regional Trauma Services                                                                          2007/2008




ORGANIZATIONAL STRUCTURE (April 1st, 2007-March 31st, 2008)

Regional Trauma Services personnel include:
Interventional Services Portfolio/Regional Trauma Services:
Ms. Andrea Robertson, Vice President, Interventional Services Portfolio
Ms. Marg Semel, Director, Inpatient Surgical Services & Trauma Services
Dr. Andrew Kirkpatrick, Regional Trauma Services Medical Director
Ms. Dianne Dyer, Regional Trauma Services Manager
Ms. Natalie Hohman, Regional Trauma Services Administrative Assistant
Dr. Kent Ranson, Regional Trauma Services Research Coordinator
Ms. Barbara Matiakis, Regional Adult Clinical Nurse Specialist
Ms. Sherry MacGillivray, Regional Paediatric Trauma Coordinator
Ms. Christi Findlay, Regional Trauma Services Data Analyst
Ms. Maria Vivas, Regional Trauma Services Data Analyst
Ms. Sukhi Lally, Regional Trauma Services Data Analyst
Ms. Michelle Mercado, Regional Trauma Services Data Analyst
Ms Alma Badnjevic, Temporary Regional Trauma Services Data Analyst
Ms. Elsie Schill, Regional Data Entry Clerk

Child & Women’s Health Portfolio: Alberta Children’s Hospital Site (ACH):
Ms. Paula Taylor, Vice President, Child & Women’s Health
Dr. Brian Stewart, Executive Medical Director, Child & Women’s Health
Ms. Toni MacDonald, Director, Child Health Programs, Child & Women’s Health
Dr. Vincent Grant, Pediatric Trauma Medical Director
Ms. Sherry MacGillivray, Regional Paediatric Trauma Coordinator
Ms. Maria Vivas, Regional Trauma Services Data Analyst

Adult Trauma/ Clinical Safety Committee Chairpersons:
Dr. Andrew Kirkpatrick: Foothills Medical Centre (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/ Clinical Safety Committee Chairperson:
Dr. Vincent Grant, ACH Trauma Committee & Clinical Safety Committee


 Acknowledgment of former personnel:
 Dr. James Silvius, Executive Medical Director, Southwest Portfolio
 Ms. Tracy Wasylak, Vice President, Southwest Portfolio
 Dr. Kent Ranson, Regional Trauma Services Research Coordinator
 Ms. Brenda Fisher, Vice President Child & Women’s Health Portfolio
 Ms. Elise Schill, Regional Trauma Services Data Entry Clerk

 Welcome to New Personnel:
 Ms. Leanne Kmet, Regional Trauma Services Research Coordinator
 Ms. Kimberly Musselwhite, Temporary Regional Trauma Services Adult Clinical Nurse Specialist

 Special Acknowledgement:
 Special thanks to Ms. Tracy Wasylak, Vice President, for her leadership and advocacy for the work of
 Trauma Services locally, provincially and nationally.




                                                   - i-
Regional Trauma Services                                                                    2007/2008




                                REGIONAL TRAUMA SERVICES

                  http://www.calgaryhealthregion.ca/programs/trauma/index.htm


                                      Calgary Health Region

Vision: Healthy Communities
Mission: Leaders in Health – a partner in Care
Values: Caring, respectful relationships, quality and safety, accountability

                                   Regional Trauma Services

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 and emergency transfers, and maintain the trauma
   registry database data and report on patients with ISS > 12 at 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.
•  Support the Trauma Association of Canada (TAC) as the TAC Central Office.



                                                - ii -
Regional Trauma Services                                                                    2007/2008




INTRODUCTION

Medical Director’s Message

Despite the many challenges facing the Calgary Health Region in particular and our national
health care system in general, Regional Trauma Services continues to enjoy great support from
the Calgary Health Region and has tremendous human and system resource advantages in our
continual goal to provide optimum clinical care to all that are injured especially the multi-system
patient. I believe the multi-disciplinary teams we have created and that cross-cut across
professions, disciplines, and sites, continue to rise to the challenge and perform in an exemplary
manner, making the Calgary Health Region a national leader in both care and systems
development. Notable items in this regard include the continuing development of a Provincial
Trauma Network that would fully meet the requirements and guidelines of the Trauma Association
of Canada. This provincial network, which was largely the product of many years work by
Dr. John Kortbeek and Ms. Dianne Dyer, continues to develop and will embrace the Foothills
Medical Centre and the regional partners including Lethbridge, Medicine Hat and Red Deer along
with the Edmonton centres linked to Grande Prairie and Fort McMurray.

Other everyday but no less remarkable accomplishments include the excellent care delivered
through comprehensive and coordinated pre-hospital ground and air ambulance services, a
single coordinated regional Emergency Department and Critical Care Departments, specialized
surgical services including the Trauma Service supported by Orthopaedic, Reconstructive,
Neurosurgical, Rehabilitative, Vascular and Spine Surgery services. The sheer volume of trauma
patients cared for in this reporting period rose sharply above the previous period provided
stresses to all involved. I truly believe that these stresses were buffered by all caregivers at all
levels who went “the extra mile” in order to continue to provide excellent care to all patients.

Research and teaching remain incredibly strong across the Regional Trauma Services and more
than anything else our future lies in educating these future providers. There is great optimism for
the future though. A Resuscitation with Angiography and Percutaneous Treatments and
Operative Resuscitation (RAPTOR) or hybrid operative suite will soon be a realty in the Calgary
Health Region. This combines surgical and angiographic resource will allow various teams of
surgeons and interventional radiologists to work together to provide the optimal care for the most
severely traumatized patient will be a resource unlike anything currently available in North
America.

On a sad note, we wish all the best of Ms. Dianne Dyer who put in many years of leadership as
Regional Trauma Manager but gladly welcome Ms. Kimberly Musselwhite as her successor as of
December 2008.




Andrew W Kirkpatrick CD MD MHSc FACS FRCSC
Calgary Health Region




                                                - iii -
Regional
Trauma
Services
EXECUTIVE SUMARRY
Regional Trauma Services                                                                       2007/2008
Executive Summary



EXECUTIVE SUMMARY
The Regional Trauma Services Program in Calgary has been in place since 1992 and was
accredited as a region by the Trauma Association of Canada (TAC) October 2004 with a report in
January 2005. Calgary was the first trauma program to be accredited as a system in Canada. The
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 include the
provision, ongoing development and advancement of clinical care, education and research
pertaining to the trauma continuum from pre-hospital to discharge to the community. The
Regional Trauma Services team continues to collaborate with partners and stakeholders, within
and external to the trauma system, to address needs, issues and to ensure an efficient, effective
integrated system of care.

The annual report is a comprehensive summary of team activities, trauma statistics, quality
performance measures, trauma research publication information and various interrelated reports
from system partners. This report is focused on April 1, 2007 through to March 31, 2008.

1. Regional Trauma Services Activities

     1.1 Clinical
     The core component of the trauma service is the clinical role to provide, 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. To support this
     goal clinical practice is enhanced through the development, implementation and evaluation of
     clinical practice guidelines, technology, quality assurance and clinical collaborative projects.

     Some of the clinical activities this year included the development of a Massive Transfusion
     Protocol for adult trauma patients, the creation and/or revision of clinical guidelines, policies
     and trauma orientation materials, and the continuation of the trauma journal club. This was
     also a year of considerable growth for the Pediatric Trauma Program at the Alberta Children’s
     Hospital (ACH). Significant events include the opening of a pediatric trauma and rehabilitation
     unit at ACH and the initiation of a dedicated trauma in-patient unit. Additionally, significant
     work was put into preparing and rolling out updated pediatric trauma team activation.

     1.2 Education
     An effective accredited trauma program must promote educational opportunities for clinical
     providers, managers, support staff and patients. Educational activities this year included
     weekly Trauma Noon Rounds, as well as, orientation sessions for new residents. The
     Trauma program staff at ACH conducted numerous educational sessions including simulation
     sessions for ACH staff and our rural partners. The monthly regional adult Grand Trauma
     Rounds were presented via Telehealth to various rural centres upon request. Monthly
     Trauma Rounds at ACH were well attended and addressed various topics pertinent to the
     unique needs of the paediatric trauma population. Some team members presented at the
     P.A.R.T.Y. (Prevention of Alcohol Related Trauma in Youth) program. Trauma Services
     continued to support the Advance Trauma Life Support (ATLS) program, the Trauma Nursing
     Core Course (TNCC) and other surgical teaching programs (e.g. Advanced Trauma
     Operative Management (ATOM)) offered across North America.

     1.3 Quality Improvement
     Part of the goal of our trauma registry is to collect information that will allow us to continually
     evaluate and improve upon the quality of the care provided to patients in the trauma system.
     The details provided in this report illuminate the impact trauma has on the patients, their
     families and the health care system as a whole. In addition to obtaining statistics for injury
     prevention strategies, ongoing evaluation of the management of trauma patients is essential
     to inform quality improvement initiatives, educational programs, research projects, protocol


                                                   1
Regional Trauma Services                                                                     2007/2008
Executive Summary



     and procedure development, and to improve decision making processes to optimize care
     provided.

     1.4 Research
     Trauma research and evidence based practice is an essential focus of Trauma Services and
     an effective trauma system. A fulltime Trauma Research Coordinator was hired in October
     2006 to support this important work. This new role provided leadership, consultation and
     support for research initiatives within the Regional Trauma Services Program as well as
     projects that related to trauma care across the region and the system.

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

     1.5 Administration
     Administrative support is essential to the co-ordination and achievement of the various
     trauma services activities. This year administrative activities continued to include work to
     implement the Provincial Trauma System proposal. The goal of the provincial trauma system
     is to provide integrated services that get the injured trauma patient to the right location, the
     right provider and the right services in a timely manner. Ongoing links were maintained with
     the Trauma Association of Canada (TAC) including management and coordination of the
     TAC Central Office and web master of the TAC web site. Funds were acquired to support
     weekly and monthly Trauma Round and the Trauma Nurses Journal Club.

     1.6 Trauma Registry
     A trauma registry is a requirement of TAC guidelines for an accredited trauma centre. FMC,
     ACH, PLC and RGH have stand-alone trauma registries. 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.

     Highlights:
         • 4715 FMC patient records and 859 ACH patient records were screened to determine
             eligibility for the trauma registry (a 13.9% and11.5% increase respectively from the
             06/07 fiscal year)
         •    1118 FMC patients, 35 PLC patients, 29 RGH patients, and 97 ACH patients
             qualified for the trauma registry
         • Males continue to outnumber females in the total adult trauma population (p. 19)
         • The majority of the trauma population fall between the ages of 15-44 (p. 21)
         • Trauma patients require extensive use of hospital resources. See p. 28 for the
             number of OR procedures performed at FMC and p. 104 for ACH; p. 30 for median
             length of stay in the ICU at FMC and p 106 at ACH
         • 36 performance indicators were reviewed for each health record included in the FMC
             registry (see p. 35); 30 were reviewed for the ACH records (p. 64). Any health
             records with performance indicators that were not met underwent further review by
             the trauma Clinical Nurse Specialist or Trauma Coordinator to determine the
             appropriate follow-up.
         • Outcomes measured at each site included death during the first 24 hours and overall
             mortality rates and discharge location

2.0 Reports
A number of reports were submitted this year from various trauma system partners for inclusion in
the annual report. The reports include:
    • Shock Trauma Air Transport Society (STARS) Report
    • The Calgary Firefighters Burn Treatment Centre Report
    • Two Tertiary Neuro-rehabilitation Program Reports


                                                  2
Regional Trauma Services                                                                2007/2008
Executive Summary



     •   An Imperative for Injury Prevention
     •   Profile of Injuries in the Calgary Health Region

These reports were written and edited by the respective programs and are an important addition
to the annual report and demonstrate and support the complexity and magnitude of the integrated
Calgary Health Region trauma system.

3.0 Future Directions
These are just a few of the Regional Trauma Services projects planned for the next year:
    • Initiate Clinical Nurse Specialist referrals through SCM.
    • Acquisition of external funding for staff education and Trauma Rounds.
    • Further development of the trauma research program.
    • Re-establish Multi-disciplinary Trauma Journal Club
    • Establishment of the fulltime Nurse Practitioner role to support clinical practice on the
    Trauma Unit.
    • Re-development of the Trauma Services internal and external website, including both
    Adult and Pediatric protocols, projects and new initiatives.
    • Continued participation and leadership in the new integrated Provincial Trauma System.
    • Continued support for the enhancement of the Pediatric Trauma Program
    • Explore different approaches to identifying trauma patients at PLC and RGH.
    • Establish an adult trauma database to facilitate the collection of prospective data to
    support timely quality improvement and clinical care initiatives.
    • Continued updates and revisions to Trauma Orientation Manuals for FMC and ACH.
    • Participation in the planning process for the new South Health Campus.
    • Implement and Evaluate the Massive Transfusion Protocol for the trauma population
    • Seek opportunities to benchmark trauma care with national and international groups.
    • Continue active participation in the Trauma Association of Canada committees,
    accreditation processes, research and support for the TAC central office.

Note: For additional detailed information on Future Directions for pediatric care please see the
ACH Trauma Program report.

For more information on the work of Regional Trauma Services visit our web site at:


                                         Trauma Services

                  http://www.calgaryhealthregion.ca/programs/trauma/index.htm




                                                  3
Regional
Trauma
Services
ACTIVITIES
Regional Trauma Services                                                                       2007/2008
Activities


REGIONAL TRAUMA SERVICES ACTIVITIES

Regional Trauma Service continues to provide support for trauma care in the following areas:

1.   Clinical

A primary role of the trauma service is to support, facilitate and evaluate the clinical services provided for
trauma patients. The goal is to improve and maintain the highest standard of trauma care through inter-
disciplinary team collaboration, education and research. To support this goal, clinical practice is enhanced
through the development, implementation and evaluation of clinical practice guidelines, technology,
quality assurance activities, and collaborative projects with other services and departments.

Note: Current protocols and practice guidelines are available to clinical providers on the Trauma Services
internal website and in the Adult Trauma Orientation Manual. The Pediatric Trauma Orientation Manual is
currently under review.

Clinical activities this year included:
• Clinical consultations on Unit 71 completed by the Clinical Nurse Specialist (CNS) as requested.
• When possible, the CNS met with patients and families in ICU prior to their transfer up to unit 71 to
    provide education and support.
• Working towards creating a method of consulting the CNS on SCM.
• Facilitation of on-going trauma quality management (formerly known as clinical safety) committee
    meetings at all sites with the intent to support the work of the committees, facilitate communication
    across the system and encourage input and feedback on trauma patient care issues and protocols.
• Working to revise the FMC Trauma Resident orientation manual. The goal was to distribute the
    manual to the residents prior to arrival for a rotation so that they have information regarding their role
    and expectations of the rotation. Monthly resident orientation was presented. Work is ongoing on this
    project.
• Working to continue to evaluate the FMC Trauma Team Activations for major trauma patients as part
    of the ongoing quality assurance reviews. If a case met the criteria for activation and the team was
    not called the case was flagged in Trauma Registry and reviewed. Patterns were identified and
    recommendations were proposed for action at the Trauma Quality Management meetings.
• Investigating the possibility of establishing a concurrent method of screening patients and conducting
    quality assurance reviews.
• Working to complete a literature review and to develop a guideline for patients flying via
     Medivac or commercial airline following chest tube removal. Many patients are from out of town, out
     of province or out of country. Once they are stabilized and able to receive the required healthcare in
     the area of residence, they are transferred closer, or discharged, to home. This project is ongoing.
• Facilitation of the review of patient issues through M+M (Morbidity and Mortality) rounds as
     required and in conjunction with Friday noon teaching rounds. Exploring options for recording M&M
    information in the SCM system and in a trauma database.
• Preliminary work was begun on investigating the feasibility of a project focused on screening patients
    involved in alcohol related trauma or potential alcohol related risk behaviours.
• Working in partnership with Diagnostic Imaging to refine the day to day processes for timely spinal
    clearance and reporting. A Regional spinal clearance guideline was finalized and was posted on the
    website. This continues to be an on-going project.
• Meetings underway to explore opportunities for angio-embolization in the FMC Trauma OR (i.e.
    logistics, funding and support)
• Initiated and developed a protocol and process for massive transfusion of the trauma patient.
• Worked with Joyce Mammel, CNS, on the Trauma Orthopaedic pain manual.
• In partnership with the trauma orthopaedic CNS established a new policy on urinary catheterization
    and the pelvic fracture patient.
• In collaboration with the APCM revised Unit 71 (Trauma Unit) specific policies.
• Continued with the trauma nursing Journal Club.
• Helped with the initiation of the Trauma Nursing Orientation.



                                                      4
Regional Trauma Services                                                                   2007/2008
Activities


Note: For detailed information on the Alberta Children’s Hospital Pediatric Trauma Program
clinical activities please see the ACH Trauma Program report.

2.   Education

Educational activities included:
• Trauma Rounds on a weekly basis at FMC and on a monthly basis at both FMC and ACH. Rounds
   were well attended and included internal and external speakers on a variety of pertinent topics. The
   adult monthly trauma rounds were presented via Telehealth to all acute care sites and rural sites
   (upon request).
• Team member attendance at the 2008 Trauma Association of Canada Scientific Meeting held in
   Whistler. External sources and minimal operations funding was used to support this. Some team
   members presented papers and posters at the meeting.
• 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.
• Working closely with the coordinator of the PARTY program to provide instructor support and
   advisory support for the program.

ATLS®

 Student Provider Courses:     2007: April 19-21, May 10-12, May 31-June 2, October 18-20, December
                               7-9

                               2008: January 17-19

 Instructor Courses:           2008: January 13-14

Dr. John Kortbeek, Calgary, AB, is Chair, ATLS Subcommittee, American College of Surgeons
Committee on Trauma, Dr. Richard Simons, Vancouver, BC, is ATLS® Region Chief for Region XII,
Western Canada, Dr. Mary vanWijngaarden-Stephens, Edmonton, AB, is Provincial Chair for Alberta and
Dr. Michael Dunham is ATLS Director for Southern Alberta. ATLS Course Directors include: Dr. John
Kortbeek, Dr. Michael Dunham, Dr. Jim Nixon, Dr. Jeff Way, Dr. Ian Anderson, Dr. Andrew Kirkpatrick,
Dr. Rohan Lall, Dr. Geoff Ibbotson and Dr. Alex Poole.

There are 43 instructors in good standing: Anaesthesia (2), Critical Care (3), Emergency Department (6),
General Surgery (23), Neurosurgery (1), Ophalmology (1), Orthopedic Surgery (5), Family Medicine (2).

ATLS® Coordinators in Calgary: Sandra Dowkes is the Administrative Coordinator and Nancy Biegler RN
MN is the On-site Coordinator, Natalie Hohman provides additional support for the Program through the
Regional Trauma Services office. The accounting part of the program moved under the umbrella of the
Department of Surgery, Calgary Health Region, in January 2006.

Information provided by: Sandra Dowkes




                                                     5
Regional Trauma Services                                                              2007/2008
Activities


                                   Trauma Education Rounds

SPONSOR ACKNOWLEDGEMENTS:

SonoSite sponsored monthly FMC Grand Trauma Rounds. Wyeth sponsor external speaker costs for
some of the rounds.

                   Trauma Grand Rounds, FMC Auditorium, 0730-0830 (Adult Program)


                                               2007
 April          “Can a Space Medicine Spin-off save lives in Northern Canada” –
                Dr. Douglas R. Hamilton
 May            Trauma Systems in Canada and the USA – Dr. Avery B. Nathens
 Sept.          A Nurse’s Experience in a War Zone – Lieutenant Tara Sawchuk
 Oct.           Management of Penetrating Abdominal Injury: The Evolution – Dr. Kenji Inaba
 Nov.           Hemodynamically Unstable Pelvic Fracture: A Panel Discussion

                                               2008
 Jan            Trauma & the Morbidly Obese Patient – Ms. Donna Stewart
 Feb            Cancelled
 Mar            Cancelled

NOTE: The Paediatric Monthly Rounds are discussed in the Paediatric Trauma Report in this
document.




                                                  6
Regional Trauma Services                                                                    2007/2008
Activities


SPONSOR ACKNOWLEDGEMENTS:
Thank you to Novo Nordisk, SonoSite, Wyeth and KCI for sponsoring FMC weekly rounds.

                           FMC Trauma Friday Noon Conference Rounds, 1200-1300
                                                   2007
 Date        Presenter                           Topic
 April
 6           CANCELLED
 13          CANCELLED
 20          Dr. Glen Vajcner                    Facial Fractures: Assessment & Management
 27          Dr. J. Green                        Assessment & Management of Acute Traumatic
                                                 Pneumothoraces
 May
 4           Multiple                            TAC Conference Prep Session
 11          CANCELLED
 18          Dr. Lynette Prediger                Delirium in Trauma
 25          Dr. C. Myden                        Pelvic Fractures & Associated Injuries
 June
 1           Dr. Michelle Riordon                Traumatic Aortic Injuries
 8           CANCELLED
 15          Dr. Curtis Myden                    Pushing the Limits in Trauma Recovery: Motivation of
                                                 Trauma Providers
 22          CANCELLED
 29          CANCELLED
 July
 6           CANCELLED
 13          Dr. Ian Maxwell                     Cardiac Injuries in Trauma: An Overview
 20          Dr. Christina Hiscox                Potential Complication in Orthopedic Trauma Patients
 27          Dr. Cinzia Gaudelli                 The Team Approach to the Trauma Patient with the
                                                 Mangled Extremity
 August
 3           CANCELLED
 10          CANCELLED
 17          Krista Reese                        VAC Dressing: Lunch & Learn
 24      Elaine Lamb                             Traumatic Pancreatits
 31      CANCELLED
 September
 7       Dr. Ian Maxwell                         Massive Transfusion in Trauma Care
 14      Dr. Janet Edwards                       Traumatic Hernias
 21      Dr. Brandan O’Neill                     The Seatbelt Sign
 28      Dianne Dyer                             What’s New in Alberta?
 October
 5       David Liu                               Hypothermia
 12      CANCELLED
 19      Hillary Austin                          Delayed Complications in Splenic Injury: A Case Review
 26
 November
 2       Dr. Rohan Lall                          M&M Review
 9       Dr. Jeremy LaMothe                      DRE: A Traumatic Experience
 16      Dr. Alyssa Reed                         Flail Chest
 23      Dr. Paul McBeth                         Whole Body CT Scans in Patients with Blunt Trauma
 30      Dr. Huey Chean                          Emergency Department Thoracotomies
 December
 7       Dr. Gavin Burgess                       Fluid & Electrolyte Balance in the Head Injured Patient
 14      CANCELLED
 21      CANCELLED
 29      CANCELLED

                                                    7
Regional Trauma Services                                                                   2007/2008
Activities




                                                  2008
 Date      Presenter                            Topic
 January
 4      Dr. Luke Harmer                        Acute Management in Pelvic Fractures
 11     Dr. Scott Cassie                       Occult Pneumothoraces
 18     Dr. Sandy Widder                       Pancreatic Trauma
 25     CANCELLED
 February
 1      CANCELLED
 8      CANCELLED
 15     Dr. Krista Wempe                       C-Spines: A Clinical Discussion, Application & Rules
 22     Dr. Mantaj Brar                        Transfusion Medicine & the Trauma Patient
 29     Dr. Jennifer Matthews                  Burn Management
 March
 7      Dr. Fred Loiselle                      Facial Fractures
 14     CANCELLED
 21     CANCELLED
 28     CANCELLED

 Teaching Opportunities
 University of Calgary weekly Trauma Conference Noon Rounds         Calgary          Continuous
 – Trauma Services
 University of Calgary Undergraduate Trauma Seminars                Calgary          Continuous
 – Trauma Services
 University of Calgary Critical Care City-wide Rounds               Calgary          Continuous
 University of Calgary Academic Half-Day Presentations              Calgary          Continuous
 Critical Care Resident Presentations                               Calgary          Continuous

3. Quality Improvement

The measurement and evaluation of various components of the adult and paediatric trauma
system is an important focus of the work of Regional Trauma Services.

Quality improvement activities throughout the year included:
• Working towards a process to review patient health records concurrently for quality
   assurance purposes.
• The quarterly and ad hoc review of FMC, PLC, RGH and ACH Trauma Registry statistics and
   the review of performance indicators and audit filters by the Trauma Coordinator/ Trauma
   CNS and as needed by the Quality Management Committee.
• The review of standards and benchmarks applied to other trauma programs in Canada and
   internationally.
• Ad-hoc Morbidity & Mortality (M&M) rounds.
   The process for M & M reviews, recording of issues, complications, and deaths is under
   review and discussions are underway to look at how this process relates to the SCM system.
• Reviewing, critiquing and creating reports, documents and policies from a trauma service
   perspective.
• On-going review of all deaths within 24 hours and all laparotomy cases through the chart
   audit processes.
• The participation by some team members as national accreditors for the Trauma Association
   of Canada.
• The posting of new or revised protocols and guidelines on the internal web site for application
   to practice.


                                                8
Regional Trauma Services                                                                       2007/2008
Activities



•    The posting of the Trauma Services Annual Report on the internal and external website and
     the Trauma Association of Canada website.
•    Working with Capital Health Region to finalize a provincial Data Dictionary for Trauma
     Registry and with national partners to finalize a national Data Dictionary.
•    Two members of the Trauma Services team presented a poster at the Trauma Association of
     Canada conference in Ottawa. The topic was Trauma Registry: A data source for economic
     and resource predictions.

4.   Research

     Major research activities included:

•    The completion of a remote telesonography pilot study with Banff Mineral Springs Hospital.
     Real-time ultrasound images from trauma patients were sent from Banff to Foothills Medical
     Centre, with a video link facilitating review and discussion of the images by physicians at both
     sites. The technology received positive reviews from users, who believe it may someday
     prove useful in more remote communities.
•    Continuation of the pilot study comparing observation with immediate chest drainage among
     stable trauma patients with occult pneumothoraces (i.e., pneumothoraces seen on CT scan
     that are not visualized on routine chest x-ray). As both safety and feasibility are evident,
     funding will be sought from the Canadian Institution of Health Research (CIHR) for a national,
     multi-centre non-inferiority trial.
•    A review of the management of blunt splenic trauma (operative vs. non-operative) in the
     Calgary Health Region over the past 10 years. The study has received Ethics approval and a
     retrospective chart review will begin in the summer.
•    Collaboration in an international observational study on the management of retained
     hemothorax being led by the American Association for the Surgery of Trauma (AAST). Ethics
     approval for this study is pending.

     Trauma Services also participates in joint research projects with the Department of Critical
     Care, and supports numerous research projects undertaken by residents and fellows. The
     research coordinator provides assistance with methodological and statistical aspects of the
     projects, and facilitates ethics review, data collection, data management/analysis and
     manuscript preparation.

5.   Administration

Administrative support is essential to the co-ordination and achievement of the various trauma
services activities.

Highlights of the year include:

•    The Provincial Trauma System
                                                                                   nd
     • Two Provincial Trauma Committee meetings were held on November 2 , 2007 in
                          th
        Calgary; March 11 , 2008 in Leduc. Terms of Reference for the committee were finalized
        and Dianne Dyer, Regional Manager for Calgary Health Region, was elected to Chair the
        committee.
     • A Trauma Advisory Team was selected to support the work of the committee and report
        to the Provincial Trauma Committee and to the PWS Working Group. The Terms of
        Reference for the committee were approved by the Provincial Trauma Committee. The
        committee was chaired by Dianne Dyer, Chair of the Provincial Trauma Committee. The
        committee prepared a preliminary Communique and Strategic Directions document for
        submission to PWS and the Alberta Health Services Board.
     • Contracts with the five Level III (District Centres) for funding were developed by the
        Calgary Health Region leadership and Legal Services. Signing is underway to ensure


                                                  9
Regional Trauma Services                                                                       2007/2008
Activities



         timely, fair and equitable distribution of funds to support the system and address any
         issues that may arise.
    •    Several rural sites hired and trained staff for positions to support quality trauma care and
         data management (e.g. Data Analysts, Trauma Coordinators/ Manager roles, Medical
         Directors). Job descriptions were developed and approved by the Provincial Trauma
         Committee.
    •    The Provincial Trauma Epidemiologist role has not been hired to date. The Provincial
         Trauma Committee approved that the position be within the mandate of the Alberta
         Centre for Injury Control & Research. This has meant obtaining approval from the Privacy
         Office for direct access to the Alberta Trauma Registry data.
                         th       th
    •    On January 9 and 10 , 2008, the Alberta Data Dictionary was finalized to be published
         for distribution across the province in May 2008.
    •    Calgary initiated and facilitated a data management course for provincial trauma staff on
         March 25th, 2008; the course focused on trauma specific ICD10 coding (13 attendees).
         On March 31st/ April 1st an Abbreviated Injury Scoring (AIS) Course was arranged in
         Vancouver with attendance by Data Analysts and Trauma Managers/Coordinators from
         Alberta, Manitoba, Ontario, British Columbia and the USA (32 attendees). This course
         was linked to the Trauma Association of Canada Scientific Meeting and coordinated
         through the Canadian Institute for Health Information (CIHI). CIHI provided funds for
         registration for all Canadian Data Analysts.
    •    Calgary provided a province wide training on the use of the ACCESS database currently
         used by the Alberta Children’s Hospital in January 2008. This database is used to track
         patients and as a communication tool between the Data Analyst and Trauma
         Coordinator.
    •    Beyond the data management training, trauma coordinators/managers and data analysts
         from district centres visited the Level I Trauma Centres to learn about their new roles and
         strategies for quality improving and reporting.

•   Trauma Association of Canada (TAC) Networks
    • Dr. Andrew Kirkpatrick assumed the role of President of TAC. Dr. John Kortbeek
        continued as Medical Director for the TAC central office and Ms. Dianne Dyer continued
        as the TAC Office Manager. All sat on the TAC Executive.
    • Ms. Natalie Hohman, Trauma Services Administrative Assistant, continued in the role of
        the Office Coordinator for the TAC central office.
    • Ms. Michelle Mercado continued as webmaster for the TAC website.
    • Ms. Christi Findlay, Data Analyst, sat on the National Executive for the Trauma Registry
        Information Specialists of Canada (TRISC).

•   Funding Acquisition and Expenditures
    • Funding was acquired from external sources to support weekly and monthly Trauma
       Rounds, and Trauma Nurses Journal Club, educational opportunities for staff and staff
       resources.
    • External and operational funding was acquired to send team members to the Trauma
       Association of Canada (TAC) Scientific meeting held at Whistler, BC in March/April 2008.
    • Funding was provided form the Trauma Association of Canada (TAC) to support the TAC
       central office coordinator and webmaster with Regional Trauma Services.
    • Advanced Trauma Life Support (ATLS®) provided some funds to support ATLS®
       secretarial support within Regional Trauma Services.
    • Annual reports were submitted to Province Wide Services (PWS) and meetings continued
       with the Regional PWS representative to ensure input into PWS funding allocations.
    • The Trauma Research Fund and smaller research funds continued to be monitored and
       managed under the University of Calgary Peoplesoft Program.
    • Funding was acquired to support a Team Retreat held at the FCJ Centre in Calgary, June
       2007. The focus was visioning and planning for the future.



                                                 10
Regional Trauma Services                                                                   2007/2008
Activities



    •    Some new staff funds were acquired to hire staff for the trauma program and to support
         new roles as leaders in the provincial system.

Committee Representation:

Calgary Health Region:
• ACH, PLC, RGH and FMC Trauma Quality Management Committees
• FMC Adult Trauma Care Committee (ATCC)
• ACH Trauma Committee
• Interventional Services Portfolio Clinical Safety Meetings
• Surgical Executive Committee
• FMC Site Managers Meetings
• City-wide Surgical Managers Meetings
• Regional Disaster Planning Committee
• FMC Disaster and Emergency Response Planning Committee
• Regional Nursing Research Committee
• Calgary, Critical Care Fellowship Steering Committee
• Trauma Fellowship Committee

Provincial:
• American College of Surgeons, Alberta Chapter
• College and Association of Registered Nurses
• Provincial Trauma Committee
• Provincial Trauma Registry, Data Management and Research Committee
• Provincial Trauma Advisory Team

National:
• The Canadian Trauma Trials Collaborative (CTTC)
• The TAC Accreditation Committee
• The TAC Executive Committee
• The TAC Abstract Review Panel
• The TAC Canadian Forces Medical Liaison/Disaster Committee
• The Royal College of Physicians & Surgeons of Canada Test Committee for General Surgery
• The Trauma Registry Information Specialists of Canada (TRISC) 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




                                                11
Regional Trauma Services                                                                     2007/2008
Activities



6. Human Resource Activities

•    Dr. Kent Ranson resigned as the Regional Trauma Services Research Coordinator in
     October 2007 to pursue his interests in international work with the World Health Organization
     in Geneva. Ms. Leanne Kmet was hired into this role in December 2007.
•    New provincial funding was approved in 2007 and utilized for 0.5 FTE data analyst support
     for the Alberta Children’s Hospital. Ms. Maria Vivas, current data analyst, continued to
     assume this role with the increased FTE. Her full-time role was then shared with FMC
     (50/50). A 0.5 FTE position was posted to provide replacement data analyst support at FMC.
•    New provincial funding was approved and utilized for a 0.5 FTE Data Entry Clerk for the
     program in 2007. Ms. Elise Schill was hired into the role in October 2007. This role was
     designed to complement the work of the data analysts and contribute to the overall data
     management and quality assurance processes. Elise however; transferred to causal in the
     role in January 2008 to be able to pursue full-time opportunities. The 0.5 FTE position was
     reposted.
•    Ms. Kimberly Musselwhite was hired as temporary full time Clinical Nurse Specialist for Adult
     Trauma in March 2008; replacing Ms. Barb Matiakis for leave.

7.   Data Management

As part of TAC guidelines, an accredited trauma centre requires a trauma registry. Both FMC and
ACH have stand-alone trauma registries in use since April 1995. The PLC and RGH, although not
accredited trauma centres, implemented the registry in the fall of 2005 as part of the Trauma
System. The software, Collector, 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, U.S., Australia, New Zealand and Sweden. It is a
complete data management tool and report writing package.

To qualify for the trauma registry, a patient must have an Injury Severity Score (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 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 highest score squared and added to produce the ISS score. The higher
the ISS score; the more severe the patient’s injuries.

To ensure all appropriate patients are included in the trauma registry, all injury admissions,
discharges and emergency department resuscitations are reviewed at FMC and ACH. This fiscal
year, 4715 (4139 06/07) FMC patient records and 859 (760 06/07) ACH patient records were
reviewed to determine eligibility for the trauma registry. This is an increase of 13.9% at FMC and
11.5% at ACH from last year. Once registry eligibility was determined, data was abstracted from
the patient record and manually entered into the trauma registry.

At the PLC and RGH, patients are selected for review based on discharge diagnosis. Please see
the PLC and RGH Reports for further information.

Data collected includes 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 Trauma Services is
authorized to collect this data:




                                                12
Regional Trauma Services                                                                                              2007/2008
Activities



27 (l) A custodian may use individually identifying health information in its custody or under its
control for the following purposes:
 (g) for internal management purposes, including planning, resource allocation, policy
development, quality improvement, monitoring, audit, evaluation, reporting, obtaining or
processing payment for health services and human resource management.

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 is retrieved and analyzed for internal quality improvement initiatives with Regional Trauma
Services (FMC, ACH, PLC and RGH Trauma Quality Management Committees and with
departments involved in the care of the trauma patient. Following the appropriate approval
process, the registry is 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.

One way the performance of the overall trauma system is measured is by collection,
documentation and review of 42 performance indicators. Thirteen of these are related to patient
flow and outcome. Twenty-nine of these are related to clinical benchmarks. All major trauma
patients are evaluated to determine if they meet the inclusion or exclusion criteria for each of the
individual performance indicators. Data management workload is directly impacted by the number
of performance indicators as well as the number of data elements collected on each major trauma
patient. Up to 1500 data elements may be collected for each patient.

The following clinical benchmark summary illustrates the number of indicators per department /
service for major trauma patients arriving at the FMC. A similar pattern is seen for patients
arriving at the ACH. For more information, please see the FMC and ACH Performance Indicator
sections later in this document.

Foothills Medical Centre -

 Department or Service                           # of clinical                 % total of overall clinical
                                                 indicators                    indicators
 Trauma / General Surgery                        7                             24.1%
 Orthopaedic Surgery                             7                             24.1%
 Emergency Department                            3                             10.3%
 Pre-hospital Care                               1                             3.4%
 Neurosurgery                                    1                             3.4%
 Plastic Surgery                                 1                             3.4%
 Spinal Service                                  1                             3.4%
 Vascular Surgery                                1                             3.4%
 Multiple Departments / Services *               7                             24.1%
* This includes indicators that are patient specific as opposed to department or service specific. An example is unplanned
return to the OR. This is related to the actual service involved in the surgery of a particular patient, not to a particular
service or department.

FMC and ACH data is submitted to the Alberta Trauma Registry (ATR) central site based at the
University of Alberta Hospital (U of A) in Edmonton, Alberta. The central site also captures data
from the U of A Hospital and the Royal Alexandra Hospital in Edmonton. Data is then submitted
from the central site to the National Trauma Registry of Canada. Currently, the information
gathered at the PLC and RGH is not sent to the central site in Edmonton and the National
Trauma Registry. In the future, inclusion of the PLC and RGH data in the submissions to the
central site and the National Trauma Registry will provide a more comprehensive picture of major
trauma in Calgary. Regional Trauma Services works closely with colleagues in Edmonton to
develop and maintain a consistent data dictionary ensuring a comprehensive and comparative
data set.

                                                             13
Regional
Trauma Injury
Statistics Summaries
FOOTHILLS MEDICAL CENTRE
ALBERTA CHILDREN’S HOSPITAL
PETER LOUGHEED CENTRE
ROCKYVIEW GENERAL HOSPITAL
Regional Trauma Services                                                                         2007/2008
Regional Trauma Injury Statistic Summaries




The following table summarizes the injury data. The codes listed below are based on the
discharge ICD-10 cause of injury codes provided by QSHI and the Trauma Registry. The ICD-10
cause of injury codes are as follows:

1.      Transportation
V01.1 – V99    Includes all types of vehicles, traffic and non-traffic, collision and non-collision

2.    Falls
W00 – W19

3.    Drowning and Threat to Breathing
W65 – W74    Drowning and submersion
W75 – W84    Other threats to breathing

4.     Exposure to smoke/fire/hot substances
X00 – X10     Exposure to smoke, fire and flames
X11 – X19     Heat and hot substances

5.     Assault
X85 – Y09

6.     Intentional Self Harm
X69 – X84

7.    Other
W20 – W49           Exposure to inanimate mechanical forces – ie. struck by or caught between
                    object, contact with sharp objects, firearm, foreign body
W50 – W64           Exposure to animate mechanical forces – hit or bumped by other person, animal
                    bites
W85 – W99           Exposure to electrical current, radiation, temperature or pressure
X20 – X29           Contact with venomous animals or plants
X30 – X39           Exposure to forces of nature
X50 – X57           Overexertion, travel and privation
X58 – X59           Other and unspecified exposure
Y10 – Y34           Event of undetermined intent
Y35 – Y36.9         Legal intervention and operations of war

Note: Poisoning, whether accidental, intentional or undetermined is not included except for that
with noxious substance which includes corrosive and caustic substances (X49, X69 and Y19)

Inpatient cases also include diagnoses of subdural hemorrhage (162.0) and coma (R402*)




                                                  15
                         Regional Trauma Services                                                                          2007/2008
                         Regional Trauma Injury Statistic Summaries




                         The following table summarizes the injury data, based on injury discharge codes provided by
                         QSHI and Trauma Registry, for the fiscal year 2003/2004 vs. 2004/2005 vs. 2005/2006 vs.
                         2006/2007vs. 2007/2008(all ages combined).


                            2003/2004                  2004/2005                2005/2006            2006/2007            2007/2008
Sites                     Injury    ISS ≥            Injury    ISS ≥          Injury    ISS ≥      Injury    ISS ≥     Injury     ISS ≥
                        Discharge     12           Discharge     12         Discharge     12     Discharge     12    Discharge      12
FMC                        3532      860              3594      895            3762      969        3758     1094       3799      1118
ACH                        696        97              737        88            748        87        705        91       778         97
PLC                        1525       22              1493       10            1464       20        1508       22       1416        35
RGH                        2017       30              1835       28            1855       33        1660       23       1722        28
Total                      7770     1009              7659     1021            7829     1109        7631     1230       7715      1278

                                                           Traumatic Injury Inpatient Summary
                                                        >18 years of age by Site and Month (QSHI)
        # of patients




                                 Apr      May        Jun       Jul    Aug     Sep     Oct   Nov       Dec   Jan      Feb     Mar
                        FMC      247       301       322       355    366      315    315       292   256   326      308     293
                        PLC      106       128       125       146    129      105    111       108   115   102      109      84
                        RGH      119       145       144       164    147      131    116       129   145   150      127     176
                        ACH        0         0          0        0     0        0      0         0     0     0        0        0

                         Totals:
                                 FMC             3696
                                 PLC             1368
                                 RGH             1693
                                 ACH             1
                         Overall Total           6757


                         Although the trauma numbers were highest in July and August there is no dramatic peak in
                         trauma injury patient admissions in any one specific month in the ≥18 year age group. Over
                         recent years, the ability to accurately predict peaks in adult trauma patient numbers is however;
                         becoming less reliable and accurate and therefore presents significant challenges for the
                         manager(s) planning for quality patient care. The numbers are consistently high and impact the
                         overall system on an on-going basis.




                                                                                16
Regional Trauma Services                                                                                                     2007/2008
Regional Trauma Injury Statistic Summaries




                                        Child Health Inpatient Pediatric Trauma Study:
                                         0-17 Years of Age by Site and Month (QSHI)
 # of patients




                       Apr     May      Jun     Jul     Aug            Sep      Oct      Nov      Dec      Jan      Feb        Mar
                 ACH   61       74      82       86       87           69       61       51       50       59       46          52
                 FMC    8        7       8       11       10            7        6        9        7       12       10           8
                 PLC    4        8       2       5        4             4        3        4        3        4       4            3
                 RGH    1        3       2       5        2             3        5        1        1        3       2            0

                            2006/2007                  2007/2008
Totals: ACH                 705                        778
        FMC                 104                        103
        PLC                 65                         48
        RGH                 27                         28

There was an increase in the total number of 0-17 year old patients admitted to ACH compared to
the previous year.


                                        Child Health Inpatient Pediatric Trauma Study:
                                         15-17 Years of Age by Site and Month (QSHI)
 # of patients




                       Apr      May     Jun      Jul      Aug          Sep       Oct      Nov      Dec      Jan      Feb         Mar
                 ACH    14       10       5       9        14           11           9    15       11           7        8           11
                 FMC    8        6        7       11          9             7        6        9        7     12          8           8
                 PLC    4        5        2       1           1             2        1        3        2        1        3           3
                 RGH    1        2        2       4           2             1        4        1        1        3        1           0


                            2006/2007         2007/2008
Totals: ACH                 108               124
        FMC                 99                98
        PLC                 37                28
        RGH                 26                22

There was a decrease in the total number of 15-17 years old patients admitted at FMC, PLC and
RGH; however, ACH saw an increase in the admissions of 15-17 years old patients.


                                                                  17
Major Trauma
Statistics &
Outcome Data
FOOTHILLS MEDICAL CENTRE
Regional Trauma Services                                                                                                                                                          2007/2008
FMC – Major Trauma Statistics & Outcome Data


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). Patients who die at
the scene of their traumatic event are not represented in this report. ISS is an anatomical scoring tool that
provides an overall score for patients with single 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.
Patients who die at the scene of their traumatic event are not included in this report. Based on the
inclusion criteria, these totals represent 29.4% of injury discharges at FMC.

In the fiscal year 2007/2008, the FMC total was 1118 patients. FMC experienced a 2.1% increase in
annual trauma case totals compared to a 12.9% increase in 2006/2007.

August accounted for the largest monthly trauma case total at FMC. Summer months were high volume
months for major trauma cases in 2007/2008.


                                          FMC - 2007/2008                                                                                    FMC - 2006/2007
                                                 137                                                                                         130
                                          118                                                                                                       112 114                 110
                                                             114
                                                       102                                                                             96                       94




                                                                                                           # of patients
                                    95
      # of patients




                       86     90                                    88                                                           78                                               80          80
                                                                          80                                               76
                                                                                73           71                                                                       66
                                                                                       64                                                                                               58




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




YEARLY TRAUMA TOTALS




                                    FMC - 5 Year Trend
                                                                      1094            1118

                             860           897
                                                        969                                             The FMC five-year trend demonstrated rising
       # of patients




                                                                                                        major trauma case numbers with a 4.1%
                                                                                                        increase in 2004/2005, an 8.0% increase in
                                                                                                        2005/2006 a 12.9% increase in 2006/2007 and
                                                                                                        a 2.1% increase for 2007/2008.        When
                                                                                                        comparing 2003/2004 to 2007/2008, there was
                                                                                                        a 30% jump in major trauma cases.
                        03/04             04/05        05/06         06/07        07/08




                                                                                                   18
Regional Trauma Services                                                                                                            2007/2008
FMC – Major Trauma Statistics & Outcome Data


MALE/FEMALE




                                   FMC - 5 Year Trend

                                                              823          818
                                                  727                                             As noted in previous trauma reports, males
      # of patients




                      646            658
                                                                                                  continued to outnumber females in the total
                                                        242         271          300              adult trauma population. For 2007/2008, the
                             214           236
                                                                                                  ratio was 2.7:1.


                      03/04          04/05        05/06       06/07            07/08

                                             Male       Female




AGE DISTRIBUTION

                                       FMC - 2007/2008
                               234

                                       193
                                                 171    164
                                                                                                  The majority of the trauma population falls
      # of patients




                                                                                                  between the ages of 15-44, with the greatest
                                                               115
                                                                                 102              representation in the 15-24 (20.9%) age
                                                                          84                      range. 68.2% of the major trauma population
                                                                                       55
                                                                                                  is between 0 and 54.
                       0

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




                                                                                             19
Regional Trauma Services                                                                                                                        2007/2008
FMC – Major Trauma Statistics & Outcome Data


MECHANISM OF INJURY (MOI)

As in previous years, MOI is reported by four broad categories: transportation, falls, violence and other.

"Transportation" continued to be cited as the “number one” MOI in data collected at FMC accounting for
45.5% of the registry cases (47.1% 2006/2007).

"Falls" resulting in major injury accounted for 35.4% of patients arriving at FMC (31.3% 2006/2007).

"Violent" causes of injury represented 12.1% of FMC major trauma patients (13% 2006/2007).
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 7% of the total at FMC (8.7% 2006/2007). “Other” is defined as unspecified, or
not within the three categories defined above. Please see Mechanism of Injury – Other for further
clarification.


                                                                                        FMC - 2007/2008

                                                               509

                                                                                             396
                                     # of patients




                                                                                                                   135
                                                                                                                                  78


                                                          Transportation                     Falls               Violence        Other




The following four pages show a further breakdown of each category:

  •   Transportation
  •   Falls
  •   Violence
  •   Other

MECHANISM OF INJURY – TRANSPORTATION


                                         FMC 2007/2008                                                        The categories used in the graph on the left
                                                                                                              represent the injured individual. For example,
                      387
                                                                                                              a pedal cyclist injured in a collision with a
                                                                                                              motor vehicle is counted as a pedal cyclist.
      # of patients




                                                                                                              Motor vehicle collisions (MVC) comprised
                                                                                                              34.6% of all major traumas at FMC, an
                                                                                                              increase from 32.9% last year. Within the
                               59                                                                             transportation category, MVC’s represented
                                                     28       31
                                                                           2        2                0        76% (69.9% 2006/2007) of all transportation
                      MVC   Pedestrian        Off Road       Pedal   Watercraft   Aircraft      Other
                                                                                                              related mechanisms of injury.




                                                                                                         20
Regional Trauma Services                                                                                                                       2007/2008
FMC – Major Trauma Statistics & Outcome Data




                                                     FMC - 5 Year Trend

                                                                                                            The graph on the left demonstrates the number
                                                                                  515           509         of traumas caused by Transportation over the
      # of patients




                                          430            449
                                                                     414
                                                                                                            past five fiscal years.




                                      03/04            04/05        05/06        06/07         07/08




MECHANISM OF INJURY - FALLS



                                                         FMC - 2007/2008
                                                   186

                                                                       145
                                                                                                            Multi-level falls continued to have the highest
                          # of patients




                                                                                                            numbers in the fall category and represent
                                                                                          65                47% of the fall category compared to 52.6%
                                                                                                            from 2006/2007. Multi-level falls make up
                                                                                                            16.6% of the total major trauma population.

                                                Multi-level         Same Level     Other/Unspecified




                                                      FMC - 5 Year Trend

                                                                                                396
                                                                       373
                                                                                  342
                      # of patients




                                            244               264




                                           03/04          04/05      05/06       06/07         07/08



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). As will be stated later in the report, falls claimed the highest
percentage of lives in the major trauma adult population this year.




                                                                                                       21
Regional Trauma Services                                                                                                         2007/2008
FMC – Major Trauma Statistics & Outcome Data



MECHANISM OF INJURY - VIOLENCE
Incidents of violence in the FMC major trauma population decreased to 135 patients this year compared
to 142 last year. Interpersonal violence is comprised of unarmed assaults, assault with a weapon and
other or unspecified assaults.

Self inflicted violence does not include intentional injury caused by poisoning.


                                        FMC 2007/2008
                                                                                              There was an increase in unarmed assaults this
                                              62                                              year to 34 (25.2%) from 32 (22.5%) in
                                                                                              2006/2007. Assaults with an object decreased
                                                                                              to 62 (45.9%) from 80 (56.3%) in 2006/2007.
      # of patients




                            34                                                                This year the number of patients with self
                                                                                              inflicted violence increased to 21 (15.6%)
                                                              21
                                                                                  18          patients from 14 (9.9%) in 2006/2007. This
                                                                                              figure does not include individuals who died at
                                                                                              the scene of their injury event or intentional
                                                                                              injury caused by poisoning.
                      Unarmed assault     Assault with   Self-inflicted    Unknown/other
                                            object                         type of assault




                                 FMC - 5 Year Trend
                                                             142
                                                                           135
                                                                                              Violence is under represented in the major
                                                                                              trauma population. Many patients experience a
                        107         106
                                                   99                                         violent assault, penetrating injury or other
      # of patients




                                                                                              violent act and do not qualify for the Trauma
                                                                                              Registry due to exclusion of many single-
                                                                                              system organ or limb injuries.


                       02/03       04/05         05/06     06/07          07/08




                                                                                         22
Regional Trauma Services                                                                                                                                   2007/2008
FMC – Major Trauma Statistics & Outcome Data



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 includes
animal attacks, and injuries sustained while riding, or in other contact with animals.


                                                     FMC 2007/2008

                                       29        30

                                                                                                                  Animal injuries made up 38.5% of the other
   # of patients




                                                                                                                  category. Mechanical injuries made up of 27.2% of
                                                                11
                                                                                                                  the other category.
                                                                                                7
                                                                             1          0

                                       1             2          3            4          5       6

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


                                                FMC - 5 Year Trend
                                                                                  95
                                        79                            83
                                                         75                                   78
       # of patients




                                       03/04         04/05           05/06       06/07       07/08




TYPE OF INJURY

‘Type of injury’ categories are used to broadly describe the type of force that results in injury. The majority
of injuries were the result of blunt forces.


                                                          FMC 2006/2007
                                             1071
                                                                                                                   Blunt trauma represented 95.8% of the total
                                                                                                                   major trauma population arriving at FMC (92.7%
                       # of patients




                                                                                                                   2006/2007). Penetrating trauma made up 3% of
                                                                                                                   the total population (5% in 2006/2007) and burns
                                                                                                                   consisted of.7% to the total population (1.7% in
                                                                 34               8                5               2006/2007).

                                             Blunt            Penetrating        Burn          Other




                                                                                                             23
Regional Trauma Services                                                                                            2007/2008
FMC – Major Trauma Statistics & Outcome Data




   Blunt Injury

                                       FMC - 5 Year Trend

                                                          1014     1071
                                                  916
                               805       812
             # of patients




                              03/04     04/05    05/06    06/07    07/08




  Penetrating Injury


                                       FMC - 5 Year Trend
                                                           55
                                         45       46
                                                                                 Penetrating trauma may not include patients
          # of patients




                               35                                      34
                                                                                 sustaining a single system/single organ injury
                                                                                 (i.e. ISS < 12) due to a stabbing incident and
                                                                                 may include patients that fall or injure
                                                                                 themselves on a sharp object.

                             03/04      04/05    05/06    06/07    07/08




  Burn Injury

                                      FMC - 5 Year Trend
                                        28

                                                          19
      # of patients




                              13
                                                                   8
                                                 2


                             03/04     04/05    05/06    06/07    07/08


For more information on adult burn cases (2007/2008) see the Calgary Firefighters Burn Treatment
Centre report.




                                                                            24
Regional Trauma Services                                                                                                    2007/2008
FMC – Major Trauma Statistics & Outcome Data




  Other Injury

                                       FMC - 5 Year Trend
                                          9
                            7                                               7
          # of patients




                                                                   6
                                                     5




                          03/04         04/05       05/06        06/07    07/08




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.

 Direct vs. Transfer

                                  FMC - 5 Year Trend

                                                    569           661        694        In 2007/2008, 62.1% of           patients were
     # of patients




                             511          512                                           transported directly from the    scene to FMC
                                                                             424        (60.4% 2006/2007) and 37.9%     of patients were
                                          382         400          433                  transferred from another        facility (39.6%
                             349
                                                                                        2006/2007).

                          03/04        04/05       05/06        06/07    07/08
                                          Direct              Transfer


CALGARY INTERHOSPITAL TRANSFERS

These patients were the major trauma patients that arrived at one site (e.g. PLC) by pre-hospital care
providers, walk-in or private vehicle and were transferred to FMC. The Peter Lougheed Centre (PLC),
Rockyview General Hospital (RGH) or the Alberta Children’s Hospital (ACH) may be the first or second
hospital prior to transfer to FMC.


                                          FMC 2007/2008

                                  41                     40
      # of patients




                                                                            2


                                PLC                   RGH                  ACH




                                                                                   25
Regional Trauma Services                                                                                                          2007/2008
FMC – Major Trauma Statistics & Outcome Data



Policies are in place in the Calgary Health Region to support and guide decisions regarding the transport
and transfer of trauma patients. These policies include the Regional Policy on “Trauma Services
Transfers” (#1353), policies and algorithms for the Southern Alberta Regional Coordinators Centre
(SARCC), EMS and STARS policies and guidelines (i.e. Pre-Hospital Index). The “Trauma Services
Transfers” policy is currently under review and being revised to include new system initiatives.



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, only the air transport portion
was represented in this collection of statistics.

  Ground vs. Air

                              FMC - 5 Year Trend
                                                                                               76% of patients were transported to the FMC
                                                                               831             Trauma Centre by ground ambulance (67.3%
      # of patients




                                                630   602        652
                         522                                                                   2005/2006). Air transport to FMC included
                                                                                               20.3% of the total major trauma population
                                                                                               (27.5% 2005/2006).
                                                                               222
                                                201    246        266
                         203

                      02/03    03/04                04/05     05/06      06/07
                                                 Ground         Air


     Private vehicle/walk-in 2006/2007: 36 (3.3%)
     Unknown mode of arrival 2006/2007: 5
     Private vehicle/walk-in 2005/2006: 51 (5.3%)




                                                                      Ground vs Rotary Wing - 2007/2008
                                                                        Transport Direct From Scene

                                                                  851
                                # of patients




                                                                                                                    165



                                                               Ground                                         Rotary Wing

                                                       Excludes patients arriving direct from scene via private vehicle/walk in




83.6% of the major trauma patients arrived to the FMC from the scene via ground ambulance (88.8% in
2006/2007). 16.2% of the major trauma patients arrived from the scene via rotary wing ambulance (16.5%
in 2006/2007).


NOTE: For more information on Ground and Air Transport see the Shock Trauma Air Rescue (STARS)
Society Report in this document.




                                                                                         26
Regional Trauma Services                                                                    2007/2008
FMC – Major Trauma Statistics & Outcome Data



ADMITTING PHYSICIAN SERVICE ANALYSIS

The majority of trauma patients at the FMC site were admitted under the services of the general surgeon,
followed by the intensivist. This complied with the performance indicator for quality trauma care and was
closely monitored. “Other” included hospitalists at the FMC site. This analysis does not include transfers
of care, nor consulting services.


                                                    FMC 2007 / 2008

                     514
     # of patients




                                 234           237


                                                              53                                45
                                                                      7            1
                     GS          ICU           NS             OS      PS          CV            Other




  Legend:
  GS - general surgery; ICU - intensive care unit; NS - neurosurgery; OS - orthopaedic surgery; PS -
  plastic surgery; CV – cardiovascular; Other – hospitalists, neurology

All cases of admission to “Other” category physicians are reviewed as part of the quality assurance
review process.




                                                         27
Regional Trauma Services                                                                                                                    2007/2008
FMC – Major Trauma Statistics & Outcome Data



SURGICAL PROCEDURES

In 2007/2008, physicians performed 1228 surgical procedures on major trauma patients at the FMC
(2006/2007 - 1121). The procedures were done during 783 visits (2006/2007 – 664) to the operating
rooms, requiring 1876 operating room hours (2006/2007 – 1779 hours).


                                                                                            FMC 2007/2008


                               497
       # of procedures




                                                  230               226                 227



                                                                                                       15      12         2          3          19

                                OS                 PS                    GS                 NS         CV      Thor       Urol     Ob/Gyn      Other




Legend:
OS - orthopaedics; PS - plastic surgery; GS - general surgery; NS - neurosurgery; CV - cardiovascular
surgery; Thor - thoracic surgery; Urol - urology; Ob/Gyn – obstetrics/gynecology; Other - anaesthesia,
radiology, etc.

Orthopaedic procedures continued to be the highest number of surgical procedures performed at FMC
(40.5% compared to 41.7% 2006/2007).

ICU TRAUMA ADMISSIONS

In 2007/2008, 275 or 24.6% (27.5% - 2006/2007) of the major trauma patients were admitted to the FMC
ICU. This does not include patients re-admitted to the ICU.



                                           FMC 2007/2008                                                Total ICU trauma admissions at the FMC were
                                           36 36
                                                                                                        288 patients. 13 patients of the 288 ICU
                                                                                                        admissions were ICU readmissions. This graph
                                                       30 31
                                                                                                        depicts ICU admissions and re-admissions. All
     # of admissions




                                     27
                         23 23                                                                          unplanned ICU admissions and readmissions
                                                                   20
                                                                                            18          were reviewed as part of the trauma quality
                                                                          16 15
                                                                                      13                assurance process. FMC major trauma ICU
                                                                                                        admissions comprised 23.6% of the total overall
                                                                                                        ICU admissions of 1220 for the fiscal year.
                         Apr   May   Jun   Jul   Aug   Sep   Oct   Nov    Dec   Jan   Feb   Mar




                                                                                                  28
Regional Trauma Services                                                                                                       2007/2008
FMC – Major Trauma Statistics & Outcome Data



 ICU TRAUMA ADMISSIONS cont.


                                             FMC - 5 Year Trend

                                                          313       320
                                               290                              288
     # of admissions




                                   254




                                   03/04      04/05      05/06      06/07       07/08




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



                                               FMC - 5 Year Trend
                                                                                      6
                                                                         5.5
                                                     5                                         All patients range 1-78 days
                                         4                      4                              Average 9.3
                       # of days




                                                                                               Standard deviation (SD) 9.8
                                                                                               Comparison: 06/07 average 7.8



                                     03/04      04/05       05/06       06/07     07/08
                                                         all patients




Improved access and patient flow was and is a priority issue for the Calgary Health Region quality
improvement initiatives. At FMC access to ICU beds has continued to be a serious challenge over the last
year. This is very relevant to the trauma program given our increasing use of ICU resources. The
Regional “no-diversion policy” was strictly upheld for trauma patients. However, it is becoming more and
more difficult with the growing demands and pressures on the system.




                                                                                          29
Regional Trauma Services                                                                                                            2007/2008
FMC – Major Trauma Statistics & Outcome Data



MEDIAN HOSPITAL LENGTH OF STAY (LOS)

The median hospital LOS has demonstrated little 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 Trend
                                      9
                         8                          8           8
                                                                              7
      # of days




                                                                                                  All patients range 1-267 days
                                                                                                  Average 13.1
                                                                                                  Standard deviation (SD) 20.0
                                                                                                  Comparison: 06/07 average 13.3

                    03/04            04/05      05/06          06/07         07/08
                                             all patients



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+).



                                       FMC 2007/2008
                                                        18.1
                                                                                                  In 2007/2008, there was an increase in the
                                                                              18.1
                                                                                      15.5        death percentage in the younger adult age
                              13.8
     % mortality




                                      11.2
                                                                                                  groups (< 65) at 62.1%.
                                              9.5              9.5

                                                                       4.3
                     0

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


                                               % Mortality




The older adult population continues to grow in numbers in the City of Calgary. The 2008 Civic Census
Summary (www.calgary.ca) indicated that the growth in the age 55-64, 65-74, 75+ population was 17,783
persons between 2004-2006 (most recent Age/Gender data was collected in 2006). The Calgary Health
Region and Regional Trauma Services will continue to face new challenges to ensure quality care and
outcomes for this complex population within the trauma system. Prevention of injury will be paramount.




                                                                                             30
Regional Trauma Services                                                                                                        2007/2008
FMC – Major Trauma Statistics & Outcome Data



OUTCOMES BY MAJOR MECHANISM OF INJURY



                                      FMC 2007/2008
                      473                                                                     At the FMC, the percentage of major trauma
                                                                                              patients who succumbed to their injuries was
                                        343
   # of Patients




                                                                                              highest for falls (13.4%), followed by, “other”
                                                                                              mechanism of injury (14.1 %), then violence
                                                           119                                (11.9%), and lastly transportation (7.1%).
                                              53                             67
                            36                                    16               11

                    Transportation        Falls               Violence        Other


                                     Survivors          Non-survivors




YEARLY OUTCOMES BY SURVIVORS/NON-SURVIVORS

The mortality rate at FMC (10.4%) has decreased when compared with 2006/2007 (10.1%).

                                     FMC - 5 year trend
    # of Patients




                                                                984         1002
                    773          797              842


                          87            97              127           110          116


                     03/04           04/05         05/06          06/07      07/08

                                     Survivors          Non-survivors




                                                                                         31
                Regional Trauma Services                                                                                                           2007/2008
                FMC – Major Trauma Statistics & Outcome Data




                OUTCOMES BY ISS

                ISS ranges captured by the trauma registry are from 12 to 75.


                                                                                            FMC 2007/2008

                                      700
                                                                    610
                                      600
                      # of patients




                                      500
                                      400
                                      300
                                      200      163                                    152
                                                                           69                            54
                                      100                                                   23                18
                                                      1                                                            14   4         7   1    2   0
                                        0
                                                12-15                   16-25         26-35              36-45     46-55          56-65    66-75

                                                                                                      ISS scores
                                                                                survivor                                    non-survivor




                DISCHARGE LOCATION

                The majority of trauma patients from both sites were 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 other/unknown category
                represents patients discharged to locations other than previously defined or for which no specific
                discharge location was documented in the chart.


                                               FMC 2007/2008
                652
# of Patients




                                      147      143
                                                                                    116
                                                            30             8                     22

                 Home                  Rehab   Acute Care   Nursing /     Home /     Died      Other /
                                                            Chronic       Support             Unknown
                                                             Care




                                                                                                         32
Regional Trauma Services                                                                                 2007/2008
FMC – Major Trauma Statistics & Outcome Data




ISS ≥ 16 TRAUMA TOTALS

In 1992, the inclusion criterion 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

                                                     953
                                             886
                                     805
  # of Patients




                  713      720
                                                                  At FMC, there has been a 33.7% increase in
                                                                  the number of patients with an ISS ≥ 16 over
                                                                  the last 5 years (03/04 – 713).


                  03/04    04/05     05/06   06/07   07/08


                                   ISS ≥16




This rise in major trauma cases has resulted in increased pressures on acute care and
community resources, with demands for improvements in access to services, technology,
performance 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.




                                                             33
Foothills
Medical
Centre
PERFORMANCE INDICATORS
Regional Trauma Services                                                                                                                  2007/2008
FMC – Performance Indicators



                                        TRANSPORT SYSTEM PERFORMANCE
                                         Interhospital Transfers within Calgary

                                (Transfers from PLC/RGH/ACH to FMC Trauma Centre)
Note: These sites may have received patients from or be a primary or secondary hospital site.

 Peter Lougheed Centre                                                   PLC Total Injury Discharges 2007/2008 = 1416
 If the patient was transferred from another hospital
 to the FMC, were they transferred from the PLC?
 n = all FMC ISS >/= 12 patients transferred from any hospital to
 FMC

 Indicator                     Yes               No

 2007/2008, n = 424            41                383                        92              91.4                93.5              90.8              90.3

 2006/2007, n = 433            40                393
                                                                                  8.0               8.6                6.5                9.2              9.7
 2005/2006, n = 400            26                374                      2003/2004      2004/2005          2005/2006         2006/2007         2007/2008


 2004/2005, n = 382            33                349
                                                                                                          %Yes         %No
 2003/2004, n = 349            28                321



Rockyview General Hospital                                               RGH Total Injury Discharges 2007/2008 = 1722
If the patient was transferred from another hospital
to the FMC, were they transferred from the RGH?
n = all FMC ISS >/= 12 patients transferred from any hospital to
FMC

Indicator                       Yes               No

2007/2008, n = 424              40                384                          90.5                                90.7                               90.6
                                                                                                 92.7                                93.8
2006/2007, n = 433              27                406
2005/2006, n = 400              37                363                                   9.5               7.3               9.3               6.2            9.4

2004/2005, n = 382              28                354                        2003/2004         2004/2005         2005/2006         2006/2007        2007/2008


2003/2004, n = 349              33                316                                                           %Yes        %No



  Alberta Children’s Hospital                                            ACH Total Injury Discharges 2007/2008 = 778
  If the patient was transferred from another hospital
  to the FMC, were they transferred from the ACH?
  n = all FMC ISS >/= 12 patients transferred from any hospital to
  FMC

  Indicator                     Yes                No

  2007/2008, n = 424            2                  422
                                                                              99.4            100.0              99.5              99.8             99.5
  2006/2007, n = 433            1                  432
  2005/2006, n = 400            2                  398
                                                                                                                        0.0
                                                                                      0.6                 0.0                             0.2               0.5
  2004/2005, n = 382            0                  382
                                                                            2003/2004         2004/2005         2005/2006         2006/2007     2007/2008

  2003/2004, n = 349            2                  347




                                                                    35
Regional Trauma Services                                                                                       2007/2008
FMC – Performance Indicators



                                                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). ISS is an anatomical scoring tool that provides an overall score for patients with
single system or multiple system injuries. The higher the ISS score the more severe the injury. Each
performance indicator number is based on the specific determinant of the indicator within the total of 1118
major trauma patients. Nurses, physicians and/or Department/Division Heads review cases of identified
non-compliance to determine the need for follow-up regarding process/system issues.

                                          PRE-HOSPITAL PHASE
  GCS (Glasgow Coma Scale) ≤ 8 at
  Scene / Airway
  Did the patient with a first recorded scene GCS ≤ 8
  receive an airway as an intervention at the scene?

  Prior to 2006/2007, this indicator monitored mechanical airways
  only. Mechanical airway included intubation (nasal and oral),
  cricothyroidotomy and tracheostomy. In 2006/2007, this indicator                                          39.2
                                                                                   47.3                                 26.6
  expanded to include Laryngeal Mask Airway (LMA) and oral or          52.9
                                                                                               58.3
  naso-pharyngeal airways as an airway intervention at the scene.

                                                                                                            60.8        73.4
                                                                       47.0        52.7
  n = all patients with first recorded scene GCS ≤8.                                           41.7
         Indicator                   Yes                No
                                                                     2003/2004   2004/2005   2005/2006    2006/2007   2007/2008

  2007/2008, n = 139           102                 37
                                                                                             %Yes        %No
  2006/2007, n = 148           90                  58
  2005/2006, n =120            50                  70
  2004/2005, n = 131           69                  62
  2003/2004, n = 121           57                  64




                                                               36
Regional Trauma Services                                                                                           2007/2008
FMC – Performance Indicators



                                    INTERHOSPITAL TRANSFERS outside Calgary

  Time Spent at Sending hospital
  Did the patient spend < 3 hours at the sending
  hospital prior to transfer to FMC trauma centre?
                                                                          30.4            36.2             59.4             38.2

  n = all patients transferred from a non-trauma centre outside
  Calgary, with a known sending hospital LOS.
                                                                                                                            61.8
                                                                          69.9            63.8             40.6

  Note: revised from < 2 hours to < 3 hours in 2004/2005                2004/2005       2005/2006       2006/2007         2007/2008
  Discrepancy over last year’s report n = 294, Yes = 175, No = 119
  Indicator                    Yes                  No                                       %Yes     %No

  2007/2008, n = 283           175                  108

  2006/2007, n = 288           117                  171

  2005/2006, n = 177           113                  64

  2004/2005, n = 181           126                  55



  District Centre Transfers
  Was the patient transferred from proposed district
  trauma centres?
  Red Deer = 27
  Lethbridge = 39
  Medicine Hat = 28

  n = all patients transferred from hospital outside Calgary             70.6         70.7          71.6          71.6         72.4

  Indicator                    Yes                  No

  2007/2008, n = 341           94                   247
                                                                         29.4         29.3          28.4           28.4        27.6
  2006/2007, n = 366           104                  262
                                                                       2003/2004    2004/2005    2005/2006    2006/2007      2007/2008
  2005/2006, n = 335           95                   240
                                                                                                 %Yes        %No
  2004/2005, n = 321           94                   227
  2003/2004, n = 286           84                   202



The Provincial Trauma System Proposal was approved for funding by Alberta Health and Wellness in
February 2007. Five centres were identified as 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 Trauma System 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). Each identified District Centre strives to
become an accredited trauma centre by the Trauma Association of Canada, which includes the
establishment of a trauma team, a trauma registry and adequate educational and equipment resources.
The Tertiary Trauma Centres (Calgary/Edmonton) will provide support to the sites as required by a
Provincial Trauma Advisory Committee.

                                                                  37
Regional Trauma Services                                                                                                  2007/2008
FMC – Performance Indicators



  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?
                                                                                    66.5        73.3         77.0                      76.3
  n = all patients transferred from a hospital outside Calgary with a                                                     78.6
  known time of injury event and known time of arrival to FMC
  Trauma Centre

  Indicator                        Yes                      No                      33.5        26.7         23.0         21.4         23.7

  2007/2008, n = 173               41                       132                   2003/2004   2004/2005    2005/2006    2006/2007   2007/2008


  2006/2007, n = 210               45                       165                                           %Yes      %No

  2005/2006, n = 126               29                       97

  2004/2005, n = 116               31                       85

  2003/2004, n = 161               54                       107



  Out of Province Transfers
  Was the patient, a non-resident of Calgary,
  transferred from out of province to Calgary?
  Of the 62 out of province transfers (non-residents of Calgary), 45
  (72.6.7%) were transferred from hospitals in British Columbia.
                                                                                                             76.0         72.7         77.0
  n = all patients transferred from a hospital outside of Calgary with patient      85.2        83.9
  home address outside of Calgary.

  Indicator                        Yes                      No
                                                                                                             24.0         27.3         23.0
                                                                                    14.8        16.1
  2007/2008, n = 270               62                       208
                                                                                  2003/2004   2004/2005     2005/2006   2006/2007     2007/2008

  2006/2007, n = 308               84                       224
                                                                                                          %Ye s     %No
  2005/2006, n = 295               72                       223
  2004/2005, n = 274               44                       230
  2003/2004, n = 270               40                       230




                                                                             38
Regional Trauma Services                                                                                 2007/2008
FMC – Performance Indicators



                                              RESUSCITATIVE PHASE

Trauma Team Activations
At FMC, the trauma team is activated at the discretion of the ED physician, using specific activation
criteria and/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 and the various providers within the trauma system.


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 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 to hospital or in the emergency department.


In cases of significant mechanism of injury 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 triage nurse, the emergency physician or the nurse
clinician may activate the Trauma Team prior to arrival of the patient, or upon arrival of the patient to the
Trauma Centre.

The second level of activation is consult only.

Nurses and/or physicians review charts when the TTA criteria are met and the trauma team is not
activated and/or the Trauma Team Leader response exceeds 20 minutes. Recommendations may be
made for action as appropriate. The activation criteria are reviewed and may be revised if appropriate by
the Adult Trauma care Committee in order to improve quality care.



Trauma Team Leader (TTL) Response Time

Was the TTL response time < 20 minutes?
                                                                    3.8          3.1         4.1         2.9           0.5

n = all patients with trauma team activation and a known trauma
team leader response time (excludes direct admits)
Unknown trauma team response times (24) excluded from
response time analysis.                                            96.2        96.9         95.9         97.1          99.5

Indicator                      Yes            No

2007/2008, n = 184             183            1
                                                                  2003/2004   2004/2005    2005/2006   2006/2007     2007/2008
2006/2007, n = 209             203            6
                                                                                          %Yes     %No
2005/2006, n = 193             185            8
2004/2005, n = 226             219            7
2003/2004, n = 210             202            8




                                                             39
Regional Trauma Services                                                                                                           2007/2008
FMC – Performance Indicators



                                                     FMC Trauma Total Comparisons

                   35                                                                                 Traum a Te am Activations any
                                                                                                      ISS
                                                                                                      M ajor Traum a Adm is s ions w ith
                   30
                                                                                                      ISS >= 12
                   25

                   20

                   15

                   10

                    5

                    0
                     Apr         M ay       Jun       Jul       Aug        Se p    Oct   Nov      De c        Jan           Fe b       M ar



In 2007/2008 there were 280 documented trauma team activations in total, 198 patients were classified as
major trauma (ISS ≥ 12).
This graph represents the number of documented trauma team activations/month (any ISS) in 2007/2008
compared with the major trauma patient (ISS ≥ 12). In some months the number of patients ISS ≥ 12 is
less than 50% of the number of patients that trigger trauma team activation. Trauma experts advise that
is better to over activate and err on the “side of caution”.



  Trauma Team Activation (TTA) Criteria in the Major Trauma Population (ISS ≥ 12)


                                             TTA Criteria Met                                                     TTA Criteria Not Met
                                               32.6% (345)                                                            67.4% (713)




              Yes, TT Activated                             No, TT Not Activated                      Yes, TT Activated              No, TT Not Activated

                   54.2% (187)                                  45.8% (158)                               1.5% (11)                      98.5% (702)




             Response Time within                                                                       Response Time within

                 20 Minutes?                                                                                20 Minutes?




             Yes                    No            Unknown Response Time                     Yes                       No              Unknown Response

          87.7% (164)            0.5% (1)                11.8% (22)                       81.8% (9)                   (0)                Time 18.2% (2)




Excludes direct admits (60)

In 2007/2008, of the 158 cases in which the criteria were met but the team was not activated, 47 (29.7%)
were single system head injured patients. In many cases of the single system head injury the patient is
referred directly to the neurosurgeon on-call and, if non-operative, the patient is admitted to the hospitalist.
If the patient qualifies as major trauma (i.e. ISS > 12) the case is flagged using the Trauma Registry and
reviewed. The concern with this type of direct referral is the potential for a missed injury when the focus is
on a single system; the tertiary survey is a critical step in the process of assessment.




                                                                              40
Regional Trauma Services                                                                                            2007/2008
FMC – Performance Indicators




 Trauma Consult
 If the trauma team was not activated, was trauma
 consulted at any time during the patient’s length of
 stay?
                                                                                       56.0
                                                                                                                    76.1

 n = all patients admitted to FMC without trauma team activation or
                                                                                       44.0
 admission to trauma services.                                                                                      23.9
 Indicator                     Yes                   No
                                                                                    2006/2007                     2007/2008

 2007/2008, n = 426            102                   324
                                                                                                  %Yes      %No
 2006/2007, n = 425            187                   238



 GCS < 8 Mechanical Airway in ED
 Did the patient with a first recorded trauma centre
 GCS < 8 receive mechanical airway intervention in
 the FMC ED?
                                                                             15.0                        23.3         16.4        15.0
 Mechanical     airway     includes   intubation         (oral,   nasal,                      25.0
 cricothyroidotomy and tracheostomy).
                       st
 n = all patients with 1 recorded trauma centre GCS ≤ 8.
 Indicator                     Yes                   No
                                                                             85.0                        76.7         83.6        85.0
                                                                                           75.0
 2007/2008, n = 40             34                    6
 2006/2007, n = 55             46                    9
 2005/2006, n = 43             33                    10                    2003/2004     2004/2005    2005/2006    2006/2007    2007/2008
 2004/2005, n = 28             21                    7
                                                                                                     %Yes       %No
 2003/2004, n = 40             34                    6



 ED Length of Stay (LOS)
 Did the patient have an FMC ED length of stay < 4
 hours?
 Median ED LOS: 5.7 hours           Range: 0 to 43.3 hours
 Average ED LOS: 7.4 hours
                                                                             62.5          57.6          63.3         68.3        66.9
 n = all patient seen in FMC ED with a known LOS.

 Indicator                     Yes                   No                                    42.4          36.7
                                                                             37.5                                     31.7        33.1
 2007/2008, n=1050             348                   702
                                                                           2003/2004     2004/2005    2005/2006    2006/2007    2007/2008
 2006/2007, n=1015             322                   693
                                                                                                     %Yes       %No
 2005/2006, n = 911            334                   577
 2004/2005, n = 840            356                   484
 2003/2004, n = 798            299                   499



                                                                    41
Regional Trauma Services                                                                                           2007/2008
FMC – Performance Indicators



Joint Reduction
If the patient had a joint dislocation (hip, shoulder,
knee, elbow) was there an attempt to relocate or a
successful relocation of the joint within 1 hour of
arrival at the FMC trauma centre?

Note: revised to include attempt at relocation of joint within 1 hour      48.6                                    37.9         45.5
                                                                                                     58.8
of arrival to FMC trauma centre in 2006/2007                                           70.6

n = All patients with a hip, shoulder, knee or elbow dislocation
with a hospital LOS ≥1 hour and a known reduction time. Wrist                                                      62.1         54.5
                                                                           51.4                      41.2
and ankles were excluded in 2005/2006.                                                 29.4
Indicator                   Yes                   No
                                                                         2003/2004   2004/2005   2005/ 2006    2006/2007   2007/2008
2007/2008, n = 12           7                     5
2006/2007, n = 29           18                    11                                             %Ye s      %No

2005/2006, n = 34           14                    20
2004/2005, n = 34           10                    24
2003/2004, n = 35           18                    17
Note: There is a discrepancy from previous reports. According to the exact definition of this indicator, it
excludes patients who have a fracture dislocation. For example, upon running the previous report
2006/2007, out of the 29 patients there were 10 patients that have a fracture dislocation, therefore n=16,
yes=12, no =4. For 2005/2006, out of 34 patients, 23 have a fracture dislocation, therefore n=11, yes=6,
no=5. The 2007/2008 report uses the exact definition of this indicator.


 CT of the Head
 If the patient had a GCS < 13, was a CT of the head                        5.2        0.0                        2.3          10.8
 performed within 4 hours of arrival at the FMC
 trauma centre?

 n = all patients with a known FMC ED GCS, a known time of CT
                                                                           95.2       100.0       92.3            97.7
 head, LOS >/= 4 hours and no head CT at sending hospital.                                                                     89.2
 Indicator                     Yes                  No

 2007/2008, n = 65             58                   7
                                                                         2003/ 2004 2004/ 2005 2005/ 2006 2006/ 2007 2007/ 2008
 2006/2007, n = 87             85                   2
 2005/2006, n = 52             48                   4                                         %Yes       %No
 2004/2005, n = 40             40                   0
 2003/2004, n = 62             59                   3




                                                                    42
Regional Trauma Services                                                                                       2007/2008
FMC – Performance Indicators



                                            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?
  Note: This indicator excludes documented subacute or chronic         13.6         11.1         20.7         17.1       14.3
  injuries.


                                                                        86.4        88.9         79.3         82.9        85.7
  n = all patients with epidural or subdural hematomas where
  operative management was the planned intervention.
  Indicator                    Yes               No
                                                                      2003/2004   2004/2005    2005/2006   2006/2007    2007/2008
  2007/2008, n= 42             36                6
  2006/2007, n= 41             34                7                                            %Yes      %No

  2005/2006, n = 29            23                6
  2004/2005, n = 36            32                4
  2003/2004, n = 44            38                6

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

                                                                        100         100           100          100          100
  n = all patients with abdominal gunshot wound admitted to FMC
  Trauma Centre.
  Indicator                    Yes               No
                                                                      2003/2004   2004/2005    2005/2006    2006/2007    2007/2008

  2007/2008, n= 6              6                 0
                                                                                              %Yes      %No
  2006/2007, n= 5              5                 0
  2005/2006, n = 4             4                 0
  2004/2005, n = 4             4                 0
  2003/2004, n = 1             1                 0




                                                                 43
Regional Trauma Services                                                                                           2007/2008
FMC – Performance Indicators



  Pelvic Fracture
  If the patient sustained a pelvic ring fracture and
  was hemodynamically unstable in the emergency
  department, was provisional stabilization done within
  12 hours of arrival to the trauma centre?
  Hemodynamically unstable: Systolic BP < 90 or greater than 4
  units of packed red blood cells given in the first hour.
                                                                          100            100             100              100
  n = all hemodynamically unstable patients with pelvic ring fracture
  and provisional stabilization
  Indicator                    Yes                  No
                                                                        2004/2005   2 0 0 5/ 2 0 0 6   2006/2007     2 0 0 7/ 2 0 0 8
  2007/2008, n = 4             4                    0
  2006/2007, n = 4             4                    0                                        %Yes       %No

  2005/2006, n = 9             9                    0
  2004/2005, n = 7             7                    0



  Pelvic Fracture
  Did this patient (from previous indicator) have their
  pelvic fracture definitively repaired within 7 days of
  arrival to trauma centre?

  Excludes patients who died prior to definitive repair


                                                                          100            100             100              100
  n = all patients with pelvic ring fracture who were
  hemodynamically unstable in ED, had provisional stabilization
  and survived at least 7 days
  Indicator                    Yes                  No
                                                                        2004/2005   2 0 0 5/ 2 0 0 6   2006/2007     2 0 0 7/ 2 0 0 8

  2007/2008, n = 1             1                    0
                                                                                             %Yes       %No
  2006/2007, n = 3             3                    0
  2005/2006, n = 7             7                    0
  2004/2005, n = 2             2                    0




                                                                  44
Regional Trauma Services                                                                                          2007/2008
FMC – Performance Indicators




  Acetabular Fracture
  If the patient sustained an acetabular fracture and
  was hemodynamically unstable in the emergency
  department, was provisional stabilization done within
  12 hours of arrival to trauma centre?
  Hemodynamically unstable: SBP < 90 or greater than 4 units of
  packed red blood cells in the first hour
                                                                         100            100                             100

  n = all hemodynamically unstable patients with acetabular
  fracture and provisional stabilization
  Indicator                    Yes                  No                 2004/2005   2 0 0 5/ 2 0 0 6   2006/2007    2 0 0 7/ 2 0 0 8


  2007/2008, n = 2             2                    0                                       %Ye s       %No
  2006/2007, n = 0             n/a                  n/a
  2005/2006, n = 2             2                    0
  2004/2005, n = 6             6                    0




  Acetabular Fracture
  Did this patient (from previous indicator) have their
  acetabular fracture definitively repaired within 7 days
  of arrival to trauma centre?

  Excludes patients who died prior to definitive repair

                                                                         100            100                              100
  n = all patients with acetabular fracture who were
  hemodynamically unstable in ED, had provisional stabilization
  and survived at least 7 days
  Indicator                    Yes                  No
                                                                       2004/2005   2005/2006          2006/2007     2007/2008
  2007/2008, n = 2             2                    0
                                                                                           %Yes        %No
  2006/2007, n = 0             n/a                  n/a
  2005/2006, n = 1             1                    0
  2004/2005, n = 1             1                    0




                                                                  45
Regional Trauma Services                                                                                             2007/2008
FMC – Performance Indicators


  Femur Fracture
  Did the patient have operative management of the
  femur fracture within 24 hours of arrival to FMC
                                                                            3.8                        12.7          7.0
  trauma centre?                                                                         13.2                                     22.2

  This indicator was reviewed by the Division of Orthopaedics and
  will remain unchanged for the 2006/2007 year. Criteria is
  undergoing further review.                                               96.2          86.8          87.3         93.0
                                                                                                                                  77.8
  n = all patients with operative management of femur fracture.
  Indicator                     Yes               No

  2007/2008, n = 54             42                12                     2003/2004     2004/2005     2005/2006    2006/2007    2007/2008


  2006/2007, n = 57             53                4                                           %Yes       %No

  2005/2006, n = 63             55                8
  2004/2005, n = 53             46                7
  2003/2004, n = 53             51                2


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                                                               23.8
                                                                         10.0
trauma centre?                                                                         16.7                                    32.4
Long bones include radius, ulna, humerus, tibia, femur and fibula.                                  37.2
This indicator was reviewed by the Division of Orthopaedics and
will remain unchanged for the 2006/2007 year.



n = all patients with operative management of open long bone             90.0                                      76.2
                                                                                       83.3                                      67.6
fracture.                                                                                            62.8
Indicator                      Yes               No

2007/2008, n = 37              25                12
                                                                       2003/2004     2004/2005     2005/2006     2006/2007    2007/2008
2006/2007, n = 42              32                10
                                                                                                     %Yes        %No
2005/2006, n = 43              27                16

2004/2005, n = 24              20                4

2003/2004, n = 40              36                4




                                                                  46
Regional Trauma Services                                                                                                  2007/2008
FMC – Performance Indicators




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



                                                                        99.2            98.5            97.3             98.0             96.8
 n = all patients with at least one operating room visit.

 Indicator                              Yes               No
                                                                                  0.8            1.5             2.7             2.0              3.2
 2007/2008, n = 469                     15                454
                                                                      2003/2004      2004/2005        2005/2006        2006/2007       2007/2008
 2006/2007, n = 444                     9                 435
 2005/2006, n = 406                     11                395                                    %Yes            %No

 2004/2005, n = 407                     6                 401
 2003/2004, n = 374                     3                 371

  Admitting Physician
  Was the patient admitted under a surgeon or
  intensivist at the FMC trauma centre?                                 3.5              2.3             3.8              2.3             3.7


  The majority of cases, determined to require review, were
  admissions to a Hospitalist.

  NOTE: Excludes patients admitted for palliative care.                 96.5            97.7            96.2             97.7            96.3

  n = all patients admitted to FMC Trauma Centre.
  Indicator                      Yes                      No

  2007/2008, n=1088              1048                     40          2003/2004      2004/2005       2005/2006         2006/2007       2006/2007

  2006/2007, n=1054              1030                     24                                     %Yes          %No
  2005/2006, n = 931             896                      351
  2004/2005, n = 864             844                      20
  2003/2004, n = 838             809                      29

  Delayed Diagnosis/Missed Injury
  Did the patient have a delayed diagnosis or missed
  injury diagnosed > 48 hours from arrival at the FMC
  trauma centre?
  Missed injuries: 50% extremity, 23.1% spine, 15.4% face, and
  7.7% thorax.
  48 hours allows time for the comprehensive tertiary survey.                                          97.5
                                                                        98.1            99.4                            98.7            98.9
  n = all patients admitted to FMC Trauma Centre who survived >
  48 hours from arrival.                                                                                                                        1.1
                                                                               1.9             0.6             2.5              1.3
  Indicator                      Yes                      No
                                                                      2003/2004      2004/2005       2005/2006       2006/2007        2007/2008
  2007/2008, n=1080              12                       1068
                                                                                                 %Yes          %No
  2006/2007, n=1035              13                       1022
  2005/2006, n = 896             22                       874
  2004/2005, n = 866             5                        861
  2003/2004, n = 839             16                       823

                                                                 47
Regional Trauma Services                                                                                                        2007/2008
FMC – Performance Indicators



  Missed C-Spine Injury
  Was there a missed c-spine injury with c-spine
  precautions removed at the FMC trauma centre?

  NOTE: Excludes patients admitted for palliative care.
                                                                         9 9 .1           9 9 .9             10 0 .0           10 0 .0            9 9 .7

  n = all patients admitted to FMC Trauma Centre.

                                                                                                                                         0 .0              0 .3
  Indicator                      Yes                      No                      0 .1               0 .1               0 .0

                                                                       2003/2004         2004/2005      2005/2006            2006/2007          2007/2008
  2007/2008, n=1089              3                        1086
  2006/2007, n=1054              0                        1054                                        %Ye s            %No

  2005/2006, n = 935             0                        935
  2004/2005, n = 867             1                        866
  2003/2004, n = 839             1                        838


 Unplanned ICU Admission
 Was there an unplanned ICU trauma admission at the
 FMC trauma centre?
 In total, there were 288 trauma patients admitted to the ICU
 (planned and unplanned) within an overall total of 1221 admissions.
 Most unplanned trauma admissions were due to respiratory
 compromise.

 n = all patients admitted to FMC Trauma Centre.                           98.0             97.0              97.6              96.5              97.5
 Indicator                     Yes                    No

 2007/2008,                    27                     1064
 n=1091                                                                                                                                                    2.5
                                                                                                     3.0               2.4               3.5
                                                                                    2.0
 2006/2007,                    37                     1022
 n=1059                                                                 2003/2004         2004/2005         2005/2006        2006/2007          2007/2008

 2005/2006, n =                22                     914
                                                                                                      %Yes             %No
 936
 2004/2005, n =                26                     841
 867
 2003/2004, n =                17                     822
 839




                                                                 48
   Regional Trauma Services                                                                                                2007/2008
   FMC – Performance Indicators




Unplanned ICU Readmission
Did the patient have an unplanned trauma
readmission to ICU at the FMC trauma centre?



n = all patients with at least one ICU admission.
                                                                       97.6         96.7          95.9           95.0           95.5


Indicator                    Yes                    No
                                                                                            3.3          4.1            5.0            4.5
                                                                              2.4
2007/2008, n = 288           13                     275
                                                                     2003/2004   2004/2005    2005/2006        2006/2007      2007/2008
2006/2007, n = 300           15                     285
                                                                                             %Yes        %No
2005/2006, n = 293           12                     281
2004/2005, n = 274           9                      265
2003/2004, n = 245           6                      239


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      20.0                                                     20.0
                                                                                                                 28.6
have failed and the patient has gone to the OR for vascular repair                                50.0
(shunt, graft or amputation).

                                                                                    100.0
n = all patients with ischemic limb, LOS ≥ 6 hours and stable                                                                   80.0
                                                                                                                 71.4
enough for OR.                                                         80.0
Indicator                  Yes                      No                                            50.0
2007/2008, n = 5           4                        1
                                                                     2003/2004   2004/2005    2005/2006        2006/2007      2007/2008
2006/2007, n = 7           5                        2
                                                                                             %Yes        %No
2005/2006, n = 2           1                        1
2004/2005, n = 3           3                        0
2003/2004, n = 5           4                        1




                                                                49
   Regional Trauma Services                                                                                              2007/2008
   FMC – Performance Indicators



Thromboembolic (DVT) Prophylaxis
Did the immobile patient receive documented
thromboembolic prophylaxis within 24 hours of                             19.2        12.5          6.6         13.1         5.6
admission at the FMC trauma centre?
This indicator includes all units with trauma patients and relies
heavily on nursing documentation of the intervention.

n = all immobile patients whose LOS ≥ 24 hours.                                                    93.4                     94.4
                                                                          80.8        87.5                      86.9
Indicator                    Yes                  No

2007/2008, n = 745           703                  42
2006/2007, n = 674           586                  88                    2003/2004   2004/2005    2005/2006   2006/2007    2007/2008

2005/2006, n = 655           612                  43
                                                                                                %Yes      %No
2004/2005, n = 546           478                  68
2003/2004, n = 511           413                  98


Major Facial Fracture
Did the patient receive operative management of
major facial fractures (mandible, maxilla or orbit) at                     7.0        6.3          8.5          4.5         4.5
the FMC trauma centre, within 7 days of injury?


n = all patients who have operative intervention of major facial          93.0        93.8         91.5         95.5        95.5
fracture.
Indicator                   Yes                   No

2007/2008, n = 45           43                    2                     2003/2004   2004/2005    2005/2006   2006/2007    2007/2008

2006/2007, n = 44           42                    2
                                                                                                %Yes      %No
2005/2006, n = 47           43                    4
2004/2005, n = 48           45                    3
2003/2004, n = 43           40                    3


Spinal Fracture
Did the patient receive operative management of
spinal fractures at the FMC trauma centre, within 7                                                 9.8          5.8         5.8
                                                                          11.4
days of injury?

n = all patients who have operative intervention of spinal fracture.
                                                                                     100.0         90.2         94.2        94.2
Indicator                   Yes                   No                      88.6

2007/2008, n = 52           49                    3
2006/2007, n = 52           49                    3                     2003/2004   2004/2005    2005/2006   2006/2007    2007/2008

2005/2006, n = 41           37                    4
                                                                                                %Yes      %No
2004/2005, n = 31           31                    0
2003/2004, n = 44           39                    5



                                                                   50
    Regional Trauma Services                                                                                       2007/2008
    FMC – Performance Indicators



                                               LAPAROTOMY CATEGORIES
    These categories include all patients with suspected intra-abdominal injury requiring a
    laparotomy. Nurses and/or physicians reviewed all laparotomy cases to determine the need for
    follow-up regarding process/system issues. 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 presenting 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?
                                                                      30.3                                  28.6        20.0
                                                                                  30.4         42.9
 2006/2007                          2007/2008
 median time to lap: 38.5 mins      median time to lap: 41 mins
 average time to lap: 227.1 mins    average time to lap: 48 mins
                                                                      69.7        69.6                      71.4        80.0
 range: 11 – 4231 mins              range: 0 – 186 mins                                        57.1
N = all patients with Category 1 laparotomy.
Indicator                  Yes                   No
                                                                    2003/2004   2004/2005    2005/2006   2006/2007    2007/2008

2007/2008, n = 21          17                    4
                                                                                            %Yes      %No
2006/2007, n = 28          20                    8

2005/2006, n = 28          16                    12

2004/2005, n = 23          16                    7
2003/2004, n = 33          23                    10




                                                               51
   Regional Trauma Services                                                                                            2007/2008
   FMC – Performance Indicators




Category 2 Laparotomies
If the patient received a category 2 laparotomy, was
it performed within 4 hours of arrival to FMC trauma
centre?
                                                                    2 3 .5       2 2 .2       12 .9          2 3 .1          2 1.7
 2006/2007                        2007/2008
 median time to lap: 120 mins     median time to lap: 124 mins
 average time to lap: 215.9       average time to lap: 186 mins
 mins
                                                                                              8 7 .1
 range: 11 – 1235 mins            range: 33 – 751 mins              7 6 .5      7 7 .8                       7 6 .9          7 8 .3

n = all patients with Category 2 laparotomy.
Indicator                  Yes                  No
                                                                   2003/2004   2004/2005     2005/2006    2006/2007      2007/2008
2007/2008, n = 23          18                   5

2006/2007, n = 39          30                   9                                          %Ye s       %No

2005/2006, n = 31          27                   4
2004/2005, n = 27          21                   6
2003/2004, n = 17          13                   4




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.

                                                                                  78.3
                                                                     87.9                       85.7            92.9            100.0
n = all patients with Category 1 laparotomy.
Indicator                                 Yes         No
                                                                                  21.7
2007/2008, n = 21                         21          0              12.1                       14.3                   7.1
                                                                   2003/2004   2004/2005     2005/2006       2006/2007       2007/2008
2006/2007, n = 28                         26          2

2005/2006, n = 28                         24          4                                    %Yes          %No

2004/2005, n = 23                         18          5
2003/2004, n = 33                         29          4




                                                              52
    Regional Trauma Services                                                                                          2007/2008
    FMC – Performance Indicators




 Therapeutic Laparotomies: Category 2
 If the patient required laparotomy at the FMC trauma
 centre, was the laparotomy therapeutic?                                     11.8     11.8          0         7.7

 Therapeutic laparotomy is defined as discovery of an injury that                                                       17.4
 requires suturing or packing.


 n = all patients with Category 2 laparotomy.                                         100       100
                                                                             88.2                             92.3
                                                                                                                        82.6
 Indicator                                 Yes        No

 2007/2008, n = 23                         19         4

 2006/2007, n = 39                         36         3                2003/2004 2004/2005 2005/2006 2006/2007 2007/2008

 2005/2006, n = 31                         31         0                                      %Yes       %No

 2004/2005, n = 27                         27         0
 2003/2004, n = 17                         15         2




Therapeutic Laparotomies: Category 3
If the patient required laparotomy at the FMC
trauma centre, was the laparotomy therapeutic?                         13.3          7.7

                                                                                               16.7
                                                                                                               33.3
Therapeutic laparotomy is defined as discovery of an injury                                                                50.0
that requires suturing or packing.
                                                                      86.7          92.3       83.3
                                                                                                               66.7
N = all patients with Category 3 laparotomy.                                                                               50.0

Indicator                                 Yes       No
                                                                    2003/2004 2004/2005 2005/2006 2006/2007 2007/2008
2007/2008, n = 14                         7         7
                                                                                             %Yes       %No
2006/2007, n = 9                          6         3
2005/2006, n = 12                         10        2
2004/2005, n = 13                         12        1
2003/2004, n = 15                         13        2




                                                              53
   Regional Trauma Services                                                                                                     2007/2008
   FMC – Performance Indicators



                                                         OUTCOMES

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

All death cases are reviewed by Trauma Services.                      39.1            41.2                            43.6            50.9
                                                                                                      55.9
n = all patients who die.

                                                                      60.9            58.8                            56.4            49.1
Indicator                                 Yes            No                                           44.1

2007/2008, n = 116                        57             59         2003/2004       2004/2005       2005/2006       2006/2007       2007/2008

2006/2007, n = 110                        62             48
                                                                                                %Yes         %No
2005/2006, n = 127                        56             71
2004/2005, n = 97                         57             40
2003/2004, n = 87                         53             34




Mortality
Did the patient die at the FMC trauma centre?




                                                                      89.9            89.1            86.9            89.9           89.6
n = all patients arriving at FMC trauma centre.
Indicator                    Yes                  No

2006/2007, n=1118            116                  1002                       10.1            10.9            13.1            10.1            10.4

2006/2007, n=1094            110                  984               2003/2004       2004/2005    2005/2006          2006/2007   2007/2008


2005/2006, n = 969           127                  842                                           %Yes         %No

2004/2005, n = 894           97                   797
2003/2004, n = 860           87                   773




                                                              54
   Regional Trauma Services                                                                                                   2007/2008
   FMC – Performance Indicators



                  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, 2007 - March 31, 2008
                               z Score                                  W Score                               Sample Size
 Adult Blunt                     1.31                                      -                                     801
 Adult Penetrating              -0.71                                      -                                     21
 Paediatric                        -                                       -                                      0
 Total Subset                    1.22                                      -                                     822

   Data: 1995 – 2008
                                         z Score                        W Score                                  Sample Size
 Adult Blunt                               5.48                          1.46                                       6501
 Adult Penetrating                         2.11                          2.33                                        282
 Paediatric                                0.63                            -                                         14
 Total Subset                              5.78                          1.50                                       6797

   For 1995 - 2008, there were 1.50 more survivors per 100 than would have been expected from
   the major trauma outcome study.

   The Alberta Trauma Registry at FMC has 9973 major trauma patient records in total. 68.2%
   (6797 patients) were eligible for z and W score while 31.8% (3176) were not eligible for the
   following reasons: not blunt or penetrating injury, missing data required for calculation of revised
   trauma score (respiratory rate, systolic blood pressure, GCS).

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



                                                                           96.9           96.4         93.9         96.3           94.6
n = all patients with probability of survival valued and probability
of survival > 20%.
Indicator                     Yes                  No                             3.1            3.6          6.1          3.7            5.4

2007/2008, n = 822            44                   778                   2003/2004      2004/2005    2005/2006    2006/2007      2007/2008

2006/2007, n = 783            29                   754                                              %Yes      %No
2005/2006, n = 688            42                   646
2004/2005, n = 587            21                   566
2003/2004, n = 536            17                   519

                                                                   55
Regional
Pediatric Trauma
Report
ALBERTA CHILDREN’S HOSPITAL




                                   ACH Trauma Services Staff

Dr. Vincent Grant .....................................................................Medical Director

Sherry MacGillivray ........................... Regional Pediatric Trauma Coordinator

Maria Vivas...................................................................................... Data Analyst
                                                     TABLE OF CONTENTS


1. Introduction ............................................................................................................................ 56

2. Clinical Care ........................................................................................................................... 57

3. Education ............................................................................................................................... 59

4. Research ................................................................................................................................ 61

5. Quality Assurance................................................................................................................... 62

6. Future Planning ...................................................................................................................... 63




                                                            APPENDICES


Appendix A .........................................................................................Trauma Quality Indicators

Appendix B ............................................................................................. Major Trauma Statistics
Regional Trauma Services                                                                  2007/2008
ACH Report



1.    Introduction

The year 2007-2008 was a year of significant growth and transition for the Pediatric Trauma
Program at the Alberta Children’s Hospital (ACH), with several key initiatives taking place to both
improve and enhance trauma care for the 0-14 year old population that we currently serve, as
well as undertake key steps to build toward the repatriation of the 15-17 year old population. In
addition, data was tracked on the needs of the 15-17 year old population, including diagnostic
imaging, operating room and in-patient bed use at the Foothills Medical Centre. Highlights
include the development of an in-patient trauma and rehabilitation unit on Unit 4, a Pediatric In-
patient Trauma Service led by the Division of Pediatric General Surgery, the implementation of a
nurse practitioner to support both in-patient trauma and rehabilitation, an overhaul of the code 77
Trauma Team Activation Guidelines and the composition of the code 77 Trauma Team.

On an education front, on-going enhancements to both internal and external pediatric trauma
education were made. The successful mock trauma code program in the ED was continued.
Pediatric Trauma Rounds were held on a monthly basis and were very well attended. The
speakers are all to be commended for excellent work in presenting very relevant clinical issues to
ACH trauma care providers. Finally, the Pediatric Trauma Program partnered with KIDSIM™, the
Pediatric Human Patient Simulation Program, to start delivering outreach pediatric trauma codes
and education to regional and rural care providers.

Our main goals continue to be strong clinical care, excellence and leadership in pediatric trauma
education both within the Alberta Children’s Hospital and to our regional partners, on-going
advocacy in injury prevention and continued productivity in quality assurance and research.

Based on our accomplishments with enhancement and expansion of pediatric trauma
services at the Alberta Children’s Hospital, the Pediatric Trauma Program was recognized
by being awarded a 2007 Calgary Health Region PeopleFirst Award, celebrating excellence
among those with exceptional performance and who embrace the Calgary Health Region’s
vision, mission and values. We were very proud to have been selected for this award, and
accepted on behalf of all trauma care providers at the Alberta Children’s Hospital.

We wish to thank all of the staff at the Alberta Children’s Hospital who have had an impact on the
Pediatric Trauma Program, and who continue to support our goals in caring for critically injured
children and youth. In particular, a great deal of thanks goes to the nurses, physicians,
respiratory therapists, and other front-line staff who remain devoted to the care of these children
and their families, as well as all of the other staff who make excellence in pediatric trauma care at
the Alberta Children’s Hospital a veritable “team effort”.




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Regional Trauma Services                                                                    2007/2008
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2.    Clinical Care

Identifying ways to improve the clinical care of the trauma patient at the Alberta Children’s
Hospital (ACH) is a major focus of the Pediatric Trauma Program. Over the past year the
following activities have been carried out:

     i)      Trauma In-patient Unit
               • A dedicated Trauma and Rehabilitation Unit was started on Unit 4 in January of
                  2008. This has allowed the care of all traumatic injuries to be consolidated within
                  one group of dedicated care providers.

     ii) Pediatric In-patient Trauma Service
           • A dedicated in-patient trauma service to provide and direct the primary clinical care
               of multiply injured trauma patients was also started in 2007-08. This has been led
               by the Division of Pediatric General Surgery, who provides attending physician
               coverage for this service. The director of the in-patient service is Dr. Mary Brindle,
               who should be commended for the wonderful work she has done in organizing this
               well-functioning team.

     iii) Pediatric Trauma Nurse Practitioner
            • This new position was started to support both the in-patient trauma service, as well
                as the medical needs of rehabilitation patients in the hospital.

     iv) Admission Guidelines for Trauma Patients
          • New guidelines were created with respect to the admitting service for pediatric
              trauma patients. Patients with isolated extremity injuries or isolated head injuries
              are admitted to orthopedics and neurosurgery respectively. All other torso trauma
              and multiply injured patients are admitted to the Pediatric In-patient Trauma
              Service.

     v) Minor Head Injury Order Set
          • A pre-established order set to streamline the admission of minor head injury
              patients requiring hospitalization was established with the Division of Pediatric
              Neurosurgery.

     vi) Trauma Team Activation Guidelines (Code 77)
           • A complete overhaul of the trauma team activation guidelines was instituted in
              October 2007. The new guidelines include anatomic, physiologic and mechanism
              of injury factors identified in the pre-hospital setting that would lead Emergency
              Department Staff to initiate a Code 77. The ultimate goal is to call the Code 77 in
              advance of patient arrival, giving the Pediatric Trauma Team enough lead time to
              be present in the Emergency Department Trauma Room on the arrival of the
              patient.

     vii)      Trauma Team Composition (Code 77)
               • A complete overhaul of the trauma team composition was also instituted in
                   October 2007. It includes the list of care providers that must attend a Code 77
                   call, as well as those that may attend at the request of the Trauma Team Leader,

     viii)     Pediatric Massive Transfusion Protocol
               • Following a request by the Pediatric Trauma Clinical Safety Committee,
                  preliminary work began on a pediatric massive transfusion protocol.




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Regional Trauma Services                                                                   2007/2008
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     ix)     Enhancement of Transfusion Medicine Services
             • Several enhancements have occurred at the ACH to make blood availability more
                streamlined. The ACH currently stocks 16 units of O type blood, with further
                supply being available from the FMC. A automated mechanism for code 77
                situations where a blood sample for typing and cross-matching is delivered to the
                blood bank at the FMC for testing, with labels being printed at the ACH for type-
                specific blood and other blood products has been established. Transfusion
                services guarantees a similar turn around time for blood products at the ACH as
                exists currently at the FMC.

     x)      Trauma Expansion Plan
             • Several of the initiatives listed above were part of a formal Trauma Expansion Plan
                 at the Alberta Children’s Hospital. Phase 1 of the Plan was designed to represent
                 enhancements required for clinical excellence in the current patient volume at ACH
                 for the 0-14 year population. These objectives contain several important steps that
                 must be fulfilled prior to entertaining expansion of the trauma population to the 15-
                 17 year population.
             • Outstanding issues from Phase 1 for 2008-09:
                       o Implementation of a designated trauma team leader roster - awaiting
                           funding
                       o Enhancement of surgical services staffing to ensure appropriate response
                           time for patients requiring urgent OR
                       o Enhancement of Diagnostic Imaging staffing to ensure appropriate
                           response time for patients requiring urgent CT (16 hrs/day x 7 days/week)
                           in-house CT response (with appropriate on-call response for other hours)
                           - awaiting funding
                       o Improvements in rehabilitation coverage and services
                       o Development of protocols to address thoracic, vascular surgery and
                           interventional radiology medical coverage
                       o A written no refusal policy for trauma patients

     xi)     Revised Drug Manual for Emergency Department
             • Currently under development

     xii)    Revised Trauma Chart for Emergency Department Nursing
             • Completed and approved

     xiii)   Revised Medication Cart for Emergency Department Trauma Room
             • Completed and approved

     xiv)    Liaising with Regional, Provincial and National Groups
             • Provincial Trauma Committee - Member
             • Trauma Coordinators of Canada - Member
             • Trauma Association of Canada - Member
             • Canadian Hospitals Injury Prevention & Reporting Prevention Programs (CHIRPP)
                 - Member




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Regional Trauma Services                                                                   2007/2008
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3.    Education

     i)   Trauma Rounds
            • April 2007 - Dr. Mary Brindle - “Coagulopathy in the Trauma Patient”

            •    June 2007 - Dr. Walter Hader - “Management of Intracranial Pressure in the
                 Traumatic Brain Injury Patient”

            •    September 2007 - Dr. Randall Berlin - “Control of the Agitated Patient”

            •    October 2007 - Dr. Kerryn Carter - “A is for Airway, Inductions and Intubations in
                 Trauma”

            •    November 2007 - Lisette Lockyer - Morbidity and Mortality Rounds

            •    December 2007 - Dr. Catherine Ross - “Injuries Associated with Near Hanging”

            •    February 2008 - Pat Bruni-Job - “Role of the Medical Examiner’s Office”

            •    March 2008 - Dr. Marc Francis - Morbidity and Mortality Rounds

     ii) Trauma Nursing Core Course
             The Trauma Nursing Core Course (TNCC) was held at the ACH for the first time this
             year. This course is designed for nurses caring for patients in any part of the trauma
             spectrum and was very well received. This course is funded twice yearly by a
             generous grant from the Alberta Children’s Hospital Foundation and will continue in
             the future.

     iii) Outreach Education
              This year was the start of the partnership between the ACH Trauma Program and
              KIDSIM™, the Pediatric Human Patient Simulation Program, to deliver education to
              both regional and rural partners. Airdrie and Black Diamond were the first two
              centers with many more booked for the next year.

     iv) Mock Trauma Codes
            Regular mock trauma codes provided residents, ED physicians, nurses, respiratory
            therapists, nursing aides and unit clerks with an opportunity to learn from simulated
            trauma codes.

     v) Emergency Nursing Trauma Education Sessions
           Monthly trauma education sessions were held for ED nurses on a sign- up basis.
           Trauma statistics, common mechanisms of injury and trauma assessment was the
           focus, but round table discussions and procedures were encouraged. These
           sessions were very well received and will continue in the future.

     vi) Emergency Nursing Trauma Simulation Sessions
            Monthly trauma simulation sessions were held for ED nurses on a sign-up basis in
            conjunction with ED residents. The Human Patient Simulator was used to facilitate
            the management of trauma patients in real time. These sessions were very well
            received and will continue in the future.

     vii) Trauma Unit Nursing Trauma Simulation Sessions
              Monthly trauma sessions using simulation were started for the new trauma unit
              nurses after three mandatory orientation days to provide trauma education. These




                                                  59
Regional Trauma Services                                                              2007/2008
ACH Report



               new trauma sessions were outlined as the ED sessions and have been popular and
               will continue in the future.

     viii)   Other Nursing Sessions
              Trauma education was included in General Nursing Orientation for new PICU and
              ED nurses at the ACH, as well as mandatory education in the ED. This year, nursing
              students have been added and are taught trauma in their clinical sessions.

     ix)     University of Calgary, Department of Pediatrics Postgraduate Medical Education
             Program
                     o Academic half-day devoted to Pediatric Trauma - Dr. V. Grant

     x)      University of Calgary, Department of Emergency Medicine Postgraduate Medical
             Education Program
                     o Academic half-day devoted to Pediatric Trauma - Dr. V. Grant
                     o Academic half-day devoted to Non-accidental Trauma in Children - Dr. V.
                         Grant

     xi)     University of Calgary, Undergraduate Medical Education
                     o Human Development Course Lecture on the Approach to Pediatric
                         Trauma - Dr. V. Grant

     xii)    Advanced Pediatric Life Support Course
                    o Trauma Lecture - Dr. V. Grant

     xiii)   Advanced Trauma Life Support
                    o Dr. V. Grant - Instructor

     xiv)    Trauma Association of Canada Annual Scientific Meeting
                    o Dr. V. Grant - Moderator of Pediatric Trauma Concurrent Sessions
                    o Dr. V. Grant - Organizing Committee




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Regional Trauma Services                                                          2007/2008
ACH Report



4.    Research


       The following research projects were in progress during 2007/2008:

          o    Hagel BE, Rowe BH, Cherry N, Jhangri G, Belton K, Dorey A. THE EFFECT OF
               BIKE HELMET LEGISLATION ON HELMET USE, HEAD INJURIES AND CYCLING
               HABITS.
          o    Belanger F, Hagel BE, Thakore S, Kyle S, Tram J, Senger T. INJURIES CAUSED
               BY NONMOTORIZED WHEELED EQUIPMENT PRESENTING TO THE ALBERTA
               CHILDREN’S HOSPITAL EMERGENCY DEPARTMENT.
          o    Hagel BE, Rowe B, Voaklander D, Jhangri G, Belton K, Kyle T. DOES VISIBILITY
               INFLUENCE THE RISK OF INJURY IN CYCLISTS?




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Regional Trauma Services                                                              2007/2008
ACH Report



5.    Quality Assurance

As part of the Regional Trauma Services quality improvement process, several performance
indicators throughout the continuum of care are monitored on a regular basis as a measure of
performance. Some of the indicators stem from audit filters set out by the American College of
Surgeons’ Committee on Trauma and Trauma Registry performance measures published by the
South Western Sydney Region Trauma Department, Liverpool, Australia. Other indicators were
developed at the ACH as site specific performance indicators. All cases flagged by a performance
indicator or audit filter are reviewed by the ACH Pediatric Trauma Clinical Safety Committee to
determine appropriateness of care and follow-up to care providers and trauma systems. The list
of performance indicators is listed below. ACH performance indicators for 2007-08 are
summarized in Appendix A.

Pre-ACH care:
    1. Presence of pre-hospital documentation from any phase of patient transport.
    2. GCS < 8 at scene with mechanical airway intervention.
    3. Length of stay at rural hospital > 2 hours.
    4. Injury time to any Trauma Center (TC) <= 4 hours.
    5. Utilization of ACH Transport team for transfer.
Resuscitative care:
    6. Trauma Team Activation.
    7. Direct admission (bypassed the Emergency Department (ED)).
    8. GCS <8 at the TC with mechanical airway intervention.
    9. Presence of ED nursing documentation every 30 minutes.
    10. Presence of sequential neurological documentation in the ED for suspected head/spinal
         cord injuries.
    11. Hypothermic in the ED (< 35.0˚C).
    12. GCS < 12 in the TC with a CT head performed within 4 hours from trauma center arrival
         (TCA).
    13. Patient stay in the ED less than 4 hours.
Definitive care:
    14. Admission to a surgeon or intensivist.
    15. Craniotomy within 4 hours after TCA with unstable epidural/subdural hematoma.
    16. Missed cervical spine injury after 48 hours from TCA without maintaining spinal
         precautions.
    17. Any laparotomy procedure performed.
    18. Femur fracture to the OR within 24 hours from TCA.
    19. Open long bone fracture to the OR within 6-12 hours from TCA (depending on the
         severity of #).
    20. Unplanned return to the OR within 48 hours of initial procedure.
    21. Missed injuries identified after 48 hours from TCA.
    22. Reduction of joint dislocation/fracture dislocation after 1 hour from TCA.
    23. Revascularization of an ischemic limb within 6 hours from the time of injury.
    24. ORIF of facial fractures within 7 days after injury.
    25. Operative repair of spinal fractures within 7 days after injury.
    26. Pelvic ring fracture/acetabular fracture (with hemodynamic instability) provisional
         stabilization > 6 hours from TCA.
    27. Definitive treatment of displaced acetabular fracture > 7 days from TCA.
    28. Unplanned PICU admission or re-admission.
Outcome:
    29. Death during the first 24 hours from TCA.
    30. Did the patient die in ACH?




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Regional Trauma Services                                                                  2007/2008
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6.    Future Planning

The 2008-2009 year will focus on the following activities:

•      Continuing implementation of phase 1 of the Pediatric Trauma Expansion Plan
              o Development of a designated trauma team leader roster
              o Enhancement of surgical services
              o Enhancement of Diagnostic Imaging services
              o Improvements in rehabilitation coverage and services
              o Development of protocols to address thoracic, vascular surgery and
                  interventional radiology medical coverage
              o A written no refusal policy for trauma patients
•      Addressing new issues identified in data collection re. the needs of 15-17 year old trauma
       patients and impact on current operations, human resources and equipment with the goal
       of eventual repatriation
•      Improving and enhancing Pediatric Trauma Rounds
•      Continuing regular TNCC courses twice yearly at ACH
•      Continuing Mock Trauma Codes in the ED as much as possible
•      Continuing excellence in pediatric trauma education within the ACH
•      Establishing excellence in pediatric trauma outreach education within the Calgary Health
       Region and throughout Southern Alberta and Southeastern British Columbia
•      Continuing advocacy of injury prevention initiatives
•      Continuing leadership on a regional, provincial and national level
•      Developing an active pediatric trauma research program
•      Continuing excellence in quality assurance leadership
•      Developing good clinical documentation tools for trauma care providers
•      Focusing on improving communication with all of the services impacted in trauma delivery
       through the Trauma Committee
•      Establishing and growing connections with other Canadian Pediatric Trauma Programs to
       work collaboratively on research, quality assurance projects and improving standards of
       care for pediatric trauma patients




NOTE:
The patients included in this report are those with an Injury Severity Score (ISS) > 12 and who
are admitted to the hospital or die in the emergency department at the Alberta Children’s Hospital
(ACH). Patients who die at the scene of their traumatic event are not represented in this report.
ISS is an anatomical scoring tool that provides an overall score for patients with single or multiple
system injuries. The ISS captured in the Alberta Trauma Registry ranges between 12 and 75. The
higher the ISS, the more serious the injury.




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  Regional Trauma Services                                                                            2007/2008
  ACH Report



  Appendix A
  Alberta Children’s Hospital Trauma Quality Indicators for 2007/2008

  Pre-ACH Care:

  1. Presence of pre-hospital documentation from any phase of patient transport.

Are all pre-hospital ambulance reports from all phases of patient transport present on the
medical record?

Exclusions: Inappropriate where patients arrived              8.0       12.8      8.8          12.8       11.2
by private vehicle, walk-ins, and unknown how
patient arrived at hospital. Unknown: missing PCR.
Inclusions: n=all patients with pre-hospital care
                                                              92.0      87.2      91.2         87.2       88.8
provider(s).

Indicator                Yes            No

2007/2008, n = 80        71             9                   2003/2004 2004/2005 2005/2006 2006/2007 2007/2008

2006/2007, n = 78        68             10
                                                                               %Yes      %No
2005/2006, n = 68        62             6
2004/2005, n = 78        68             10
2003/2004, n = 88        81             7

  Pre-hospital documentation is sometimes difficult to obtain. Every attempt is made to locate
  missing Patient Care Records (PCR) from the various ambulance services.

  2. Glasgow Coma Scale (GCS) <=8 at scene with mechanical airway intervention.

Did the patient with a first recorded scene GCS <=8 receive a mechanical airway as an
intervention at the scene?

Mechanical airway includes: oral intubation, nasal
intubation, tracheostomy, and cricothyroidotomy. It
does not include nasopharyngeal airway, laryngeal                       55.6      53.8                    52.9
mask (LMA) or oropharyngeal airway.                           75.0                             80.0
Exclusions: Inappropriate - patients with unknown
GCS, patients without prehospital care, intubated                       44.4      46.2                    47.1
patients prior to GCS calculation.                            25.0                             20.0
Inclusions: n = all patients with first recorded GCS
                                                            2003/2004 2004/2005 2005/2006 2006/2007 2007/2008
≤ 8 at the scene.
                                                                               %Yes      %No
Indicator                Yes            No

2007/2008, n = 17        8              9
2006/2007, n = 15        3              12
2005/2006, n = 13        6              7
2004/2005, n = 18        8              10
2003/2004, n = 12        3              9

  Pediatric experts advise that it is best practice to move the injured pediatric patient from the
  scene quickly to acute care for intubation, if required, rather than attempt intubation at the scene.



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  Regional Trauma Services                                                                              2007/2008
  ACH Report



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

Was the length of stay at a rural hospital > 2 hours?

Exclusions: Inappropriate - patients had no first or
second hospital. Unknown - missing arrival or                             25.0
                                                                37.0                29.0                    39.3
departure time at first or second hospital                                                       58.0
Inclusions: n = all patients arriving at ACH from
hospital outside Calgary.
                                                                63.0      75.0      71.0                    60.7
                                                                                                 42.0
Indicator                Yes               No
                                                              2003/2004 2004/2005 2005/2006 2006/2007 2007/2008
2007/2008, n = 28        17                11
2006/2007, n = 26        11                15                                    %Yes      %No

2005/2006, n = 31        22                9
2004/2005, n = 24        18                6
2003/2004, n = 41        26                15

  If at any time the ACH Pediatric Trauma Clinical Safety Committee feels that the Rural Hospital
  LOS is not acceptable, a letter to that hospital is sent for clarification of the timeline and
  appropriately followed up. In 2007/2008 note the increase in the number of cases that stayed at
  rural hospitals for more than 2 hours. With outreach education and follow up on cases, it is hoped
  this number decreases.

  4. Injury time to any trauma centre < 4 hours.

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.
                                                                30.8
Exclusions: Out of the 31 patient transfers, 3                                                   53.6       60.7
patients were transferred from within Calgary,                            73.9      82.1
resulting in a total (n) of 28 patients for this indicator.
                                                                69.2
Inclusions: n = all patients transferred from a                                                  46.4       39.3
hospital outside Calgary with a known time of injury                      26.1      17.9
and known time of arrival.
                                                              2003/2004 2004/2005 2005/2006 2006/2007 2007/2008

Indicator                Yes               No                                    %Yes      %No
2007/2008, n = 28        11                17
2006/2007, n = 28        13                15
2005/2006, n = 28        5                 23
2004/2005, n = 23        6                 17
2003/2004, n = 65        45                20

  A high number of patients were not seen at a Trauma Centre within the 4 hour cutoff. Although
  many factors contribute to delays, most are found to be related to challenges in mobilizing
  transfer of patients from rural health centers.




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  Regional Trauma Services                                                                             2007/2008
  ACH Report



  5. Utilization of ACH Transport team for transfer.

ACH Transport Team Utilization
Was the patient transported by the ACH Transport
Team?


                                                               85.1      75.8      80.5         81.4       85.6

Inclusions: n=all patients transferred        from a
primary or secondary hospital.                                 14.9      24.2      19.5         18.6       11.4
                                                             2003/2004 2004/2005 2005/2006 2006/2007 2007/2008
Indicator                Yes            No
2007/2008, n = 35        4              31                                      %Yes      %No

2006/2007, n = 43        8              35
2005/2006, n = 41        8              33
2004/2005, n = 33        8              25
2003/2004, n = 47        7              40

  The Alberta Children’s Hospital offers a specialized Pediatric Transport Team Service, which
  transports critically ill or injured children from referring centers located in southern Alberta, south-
  eastern British Columbia, and south-western Saskatchewan. The transport team travels by
  ambulance, helicopter or fixed-wing aircraft and provides quality pediatric critical care to the
  residents of these areas who do not otherwise have access to pediatric critical care specialists.
  Through Link Center communications, medical control and mobilization of the team is achieved
  via the PICU attending physician. The team consists of a respiratory therapist (RT) and an ACH
  ICU registered nurse (RN) with a physician on call for difficult cases. An external audit review was
  done this past year to help identify any areas of potential improvement within this team – the final
  report has not been presented as of yet.




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      Regional Trauma Services                                                                                                                                    2007/2008
      ACH Report



      Resuscitative care:

          6. Trauma Team Activation

                                                               Major Trauma Team Activation
                                                                   2005/2006 to 2007/2008

                                                                                       5                    5
 # of Activations




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

                    A pr        M ay         J un         J ul          A ug       Sep              Oct             Nov         D ec      Jan           F eb          M ar


                                                                     2005/2006         2006/2007                   2007/2008


      In the past, activation of the trauma team (Code 77) was initiated through the ED at the discretion
      of the ED physician. With that process, it was felt there were a number of patients that should
      have had an activation. Starting in October of this year, the activation criteria was changed
      dramatically to include physiological, anatomical, co-morbid factors and mechanism of injury. The
      activation was put on the responsibility of the ED nurse answering the EMS patch phone using
      these criteria. Thus in 2007/2008 there were 35 activations, more than in the past years. The
      above graph illustrates Code 77 activation for the major trauma population only (ISS > 12). In
      some cases, the trauma team may be called however; the patient does not meet the Trauma
      Registry inclusion criteria.

      7. Direct Admission - Bypassed the Emergency Department (ED)

Direct Admission

Exclusions: ED deaths
Inclusions: n=all patients who were admitted to the
trauma centre.
                                                                                                                  85.0         89.0      83.0           89.0          91.8
Indicator                                   Yes                            No
2007/2008, n = 97                           8                              89
2006/2007, n = 90                           10                             80                                     15.0         11.0      17.0           11.0             8.3
2005/2006, n = 86                           15                             71                                   2003/2004 2004/2005 2005/2006 2006/2007 2007/2008

2004/2005, n = 83                           9                              74
                                                                                                                                       %Yes       %No
2003/2004, n = 96                           14                             82

      There is currently a No Direct Admit Policy for trauma patients, however in 2007/2008 there were
      4 patients that were admitted directly to an inpatient unit from our regional adult trauma center -
      Foothills Medical Center after 24 hours post injury. The remaining 4 patients have been reviewed
      at the Pediatric Trauma Clinical Safety Committee.




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  8. GCS <=8 at the trauma centre (TC) with mechanical airway intervention.

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


Exclusions: Patients with GCS>8 at ACH-ED.
                                                             0        0         0           0          0
Inclusions: n = all patients with first recorded
trauma centre GCS ≤ 8.
Indicator             Yes                 No
                                                            100      100       100         100       100
2007/2008, n = 9         9              0
2006/2007, n = 4         4              0
                                                         2003/2004 2004/2005 2005/2006 2006/2007 2007/2008
2005/2006, n = 5         5              0
2004/2005, n = 2         2              0                                  %Yes      %No

2003/2004, n = 3         3              0

  9. Presence of ED nursing documentation every 30 minutes.

After arrival at the trauma centre, was q 30 documentation present on the ED record for the ED
length of stay?


Exclusions: Direct admits and unknown/missing ED
notes.
                                                                      37        31                    33
Inclusions: n = all patients seen in ED.                    48                             42
Indicator             Yes              No

2007/2008, n = 89        60             29                            63        69                    67
                                                            52                             58

2006/2007, n = 81        47             34
                                                         2003/2004 2004/2005 2005/2006 2006/2007 2007/2008
2005/2006, n = 72        50             22
2004/2005, n = 79        50             29                                 %Yes      %No

2003/2004, n = 81        42             39

  This year the Emergency Trauma Record was revised which has helped to increase compliance
  of this indicator. Further teaching and education sessions will hopefully keep up this momentum.




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  10. Presence of sequential neurological documentation in the ED for suspected head/spinal cord
  injuries

After arrival at the trauma centre, was sequential neurological documentation present on the
ED record for the ED length of stay, if the patient had a diagnosis of skull fracture, intracranial
injury, or spinal cord injury?


Exclusions: Direct admits and unknown/missing ED
notes.                                                     19          26           17.5         26           31.4
Inclusions: n = all patients seen in ED
Indicator             Yes               No
                                                           81          74           82.5         74
2007/2008, n = 70        48          22                                                                       68.6

2006/2007, n = 61        45          16
                                                        2003/2004 2004/2005 2005/2006 2006/2007 2007/2008
2005/2006, n = 40        33          7
2004/2005, n = 38        28          10                                       %Yes         %No

2003/2004, n = 52        42          10

  Trauma Packs which include a separate Neurological Vital Sign sheet are in the ACH ED Trauma
  Room to remind nurses to trend this important vital sign.

  11. Hypothermic in the ED (<35.0 degrees C)

Was the patient hypothermic in the emergency department? Temperature was recorded at
<35.0 degrees C.


Exclusions: Direct admits and unknown/missing ED
temp.
Inclusions: n = all patients seen in ED.
Indicator             Yes              No                 93.4         93.0         92.6         98.7         97.6
2007/2008, n = 83        1           82
                                                                 6.6          7.0          7.4          1.3          1.5
2006/2007, n = 77        1           76
                                                        2003/2004 2004/2005 2005/2006 2006/2007 2007/2008
2005/2006, n = 68        5           63
2004/2005, n = 71        5           66                                       %Yes         %No

2003/2004, n = 76        5           71

  In 2007/2008 one trauma patient was identified as hypothermic in the ED however both warmed
  fluids and forced air (bair hugger) were used to actively warm this patient.




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  12. GCS <12 in the TC with a CT head performed within 4 hours of trauma centre arrival (TCA).

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

                                                                               0.0         0.0
Exclusions: Inappropriate – GCS >=12, intubated
                                                                     0.0                               0.0
patients arriving in ACH. Unknown – missing GCS           16.7
documentation.
Inclusions: n = all patients with a known ED GCS
                                                                   100.0      100          100        100.0
and a known time of CT head.                              83.3

Indicator                Yes          No

2007/2008, n = 10        10           0                 2003/2004 2004/2005 2005/2006 2006/2007 2007/2008

2006/2007, n = 6         6            0                                    %Yes      %No

2005/2006, n = 6         6            0
2004/2005, n = 5         5            0
2003/2004, n = 6         5            1



  13. Patient stay in ED less than 4 hours.

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


Exclusions: Direct Admissions and unknown ED
LOS.
Inclusions: n=all patients seen in ACH ED with a          43.6      38.9      37.9         33.3       37.1
known ED LOS.
Indicator            Yes             No
                                                          56.4      61.1      62.1         66.7       62.9
2007/2008, n = 89        56           33
2006/2007, n = 66        44           22                2003/2004 2004/2005 2005/2006 2006/2007 2007/2008

2005/2006, n = 70        44           26
                                                                           %Yes      %No
2004/2005, n = 77        47           30
2003/2004, n = 78        44           34

  ED LOS continues to be a problem. All cases are reviewed at the Pediatric Trauma Clinical
  Safety Committee and recommendations are made for those that are not deemed appropriate.




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  Definitive care:

  14. Admission to a surgeon or intensivist.

Was the patient admitted to a surgeon or an intensivist at the ACH trauma centre?


Exclusions: ED deaths.
Inclusions: n = all patients admitted to ACH                16.7      18.1      22.1         20.0       11.2
Trauma Centre.
Indicator             Yes               No
                                                            83.3      81.9      77.9         80.0       88.8
2007/2008, n = 89        79            10
2006/2007, n = 90        72            18
                                                          2003/2004 2004/2005 2005/2006 2006/2007 2007/2008
2005/2006, n = 86        67            19
2004/2005, n = 83        68            15                                    %Yes      %No

2003/2004, n = 96        80            16

  In 2007/2008, 10 patients were admitted to the hospital-based pediatricians. This year the
  development of an in-patient trauma service led by General Surgery and a dedicated unit for
  trauma patients was created. Despite this development, there is still a group of patients that are
  admitted under the pediatricians as this is deemed the most appropriate service. All these cases
  are reviewed.

  15. Craniotomy within 4 hours after TCA with unstable epidural/subdural hematoma.

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

Exclusions: Inappropriate – all patients without
                                                             0                   0            0           0
epidural or subdural hematoma.                                         25
Inclusions: n = all patients with epidural or
subdural hematoma where operative management
was the planned intervention.                               100                 100          100        100
                                                                       75
Indicator             Yes              No

2007/2008, n = 3         3             0
                                                          2003/2004 2004/2005 2005/2006 2006/2007 2007/2008
2006/2007, n = 4         4             0
                                                                             %Yes      %No
2005/2006, n = 1         1             0
2004/2005, n = 8         6             2
2003/2004, n = 4         4             0




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

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


Exclusions: ED deaths.
Inclusions: n = all patients admitted to ACH
Trauma Centre.
Indicator          Yes           No
                                                           100          100          100          100          100
2007/2008, n = 94        0            94
2006/2007, n = 90        0            90
                                                         2003/2004 2004/2005 2005/2006 2006/2007 2007/2008
2005/2006, n = 86        0            86
2004/2005, n = 83        0            83                                       %Yes         %No

2003/2004, n = 96        0            96

  17. Any laparotomy procedure performed.

Did the patient require a laparotomy?

Exclusions: None
Inclusions: n = all major trauma patients.

Indicator                Yes          No
                                                           96.9         97.7         95.4         98.9         95.5
2007/2008, n = 88        4            84
                                                                  3.1          2.3          4.6          1.1          4.5
2006/2007, n = 91        1            90
                                                         2003/2004 2004/2005 2005/2006 2006/2007 2007/2008
2005/2006, n = 87        4            83
2004/2005, n = 88        2            86                                       %Yes         %No

2003/2004, n = 97        3            94

  In 2007-08, 4 patients required a laparotomy. Two for hemodynamically unstable splenectomies,
  one for a duodenal injury and one for a pre-peritoneal hematoma. This continues to reflect the
  current conservative and non-operative approach of pediatric patients with solid organ injuries.




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

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


Exclusions: No femur fracture or no surgical                11.1
                                                                      25.0        40
intervention planned.                                                                        20
Inclusions: n = all patients requiring operative                                                       50
management of femur fracture.
Indicator             Yes               No                  88.9
                                                                      75.0                   80
                                                                                 60
                                                                                                       50
2007/2008, n= 4          2             2
2006/2007, n = 5         1             4                  2003/2004 2004/2005 2005/2006 2006/2007 2007/2008

2005/2006, n = 5         3             2
                                                                             %Yes      %No
2004/2005, n = 8         6             2
2003/2004, n = 9         8             1

  In 2007/2008 there were two patients that were not taken to the OR within 24 hours. The
  Pediatric Trauma Clinical Safety Committee felt it was an appropriate decision as these patients
  were not stable enough for this type of surgery. Both patients had appropriate traction in place
  within a satisfactory timeframe.

  19. Open long bone fracture to the OR after 6-12 hours from TCA (depending on the severity of
  the fracture).

Did the patient with open long bone fracture have operative management performed within 6
hours (grade 3) or 12 hours (grade 1, 2) of arrival to ACH trauma centre?


The long bones include the radius, ulna, humerus,
tibia, femur and fibula.

Exclusions: No open long bone fractures; patients
                                                            100       100                              100
with open long bone #s but too unstable for
operative repair within the timeframe; patients with
open long bone #s who died within the timeframe.                                 0           0
Inclusions: n = all patients requiring operative         2003/2004 2004/2005 2005/2006 2006/2007 2007/2008
management of open fracture where grade of
fracture is known.                                                           %Yes      %No

Indicator                Yes           No

2007/2008, n = 1         1             0
2006/2007, n = 0         0             0
2005/2006, n = 0         0             0
2004/2005, n = 2         2             0
2003/2004, n = 4         4             0




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

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


Exclusions: No operating room visit.
Inclusions: n = all patients with at least one
operating room visit.
Indicator             Yes                No                                94.1
                                                              100                       100         93.7       96.3
2007/2008, n = 27        1              26
                                                                                              0.0                      3.7
2006/2007, n = 23        1              22
                                                            2003/2004 2004/2005 2005/2006 2006/2007 2007/2008
2005/2006, n = 28        0              28
2004/2005, n = 34        2              32                                        %Yes        %No

2003/2004, n = 31        0              31

  In 2007/2008 one unplanned return to the OR was for an unstable splenectomy patient that
  continued to bleed. The Pediatric Trauma Clinical Safety Committee deemed that there was
  appropriate management in this case.

  21. Missed injuries identified after 48 hours from TCA.

Did the patient have a delayed diagnosis or missed injury at the ACH trauma centre?


Exclusions: ED deaths.
Inclusions: n = all patients admitted to ACH
Trauma Centre.
Indicator         Yes            No
                                                              97.9         96.4         99          100        100
2007/2008, n = 94        0              94
                                                                     2.1          3.6          1           0           0
2006/2007, n = 90        0              90
                                                            2003/2004 2004/2005 2005/2006 2006/2007 2007/2008
2005/2006, n = 86        1              85
2004/2005, n = 83        3              80                                        %Yes        %No

2003/2004, n = 96        2              94




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

If the patient had a joint dislocation or fracture dislocation (hip, shoulder, knee, elbow), was it
reduced within first hour of TCA.


Exclusions: No joint dislocation, died within first
hour, wrist or ankle dislocations.
Inclusions: n = all patients with joint dislocation or
fracture dislocation who survived at least 1 hour.

Indicator                Yes             No
                                                                0.0            0.0           0.0
2007/2008, n = 0         0               0                      0.0            0.0           0.0
                                                              2005/2006     2006/2007      2007/2008
2006/2007, n = 0         0               0
                                                                           %Yes      %No
2005/2006, n = 0         0               0



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

If the patient had an ischemic limb, was it re-vascularized within 6 hours from the time of
injury?


Exclusions: No ischemic limb or patient died prior
to repair.
Inclusions: n = all patients with ischemic limb.

                                                                1.0

Indicator                Yes             No
                                                                 0.0           0.0           0.0
2007/2008, n = 0         0               0                                     0.0           0.0
                                                              2005/2006     2006/2007      2007/2008
2006/2007, n = 0         0               0
                                                                           %Yes      %No

2005/2006, n = 1         0               1




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

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


Exclusions: No major facial fractures or died prior
to repair.                                                                            0                         0
Inclusions: n = all patients requiring operative
management of major facial fractures who survive at
least 7 days.                                                 100                    100                      100
                                                                                                 83.3
                                                                           66.7
Indicator            Yes                No

2007/2008, n = 2         2              0
                                                            2003/2004 2004/2005 2005/2006 2006/2007 2007/2008
2006/2007, n = 6         5              1
                                                                                  %Yes     %No
2005/2006, n = 4         4              0
2004/2005, n = 3         2              1
2003/2004, n = 3         3              0



  25. Operative repair of spinal fractures within 7 days of injury.

If the patient had an operative repair of spinal fractures, was it completed within 7 days of
injury?


Exclusions: No operative repairs or patient died
prior to repair.
Inclusions: n = all patients with operative repair of
spinal fracture who survive at least 7 days.

Indicator                Yes            No
                                                                    0.0              0.0                  0.0
2007/2008, n = 0         0              0                           0.0              0.0                  0.0
                                                               2005/2006           2006/2007            2007/2008
2006/2007, n = 0         0              0
                                                                                  %Yes     %No

2005/2006, n = 0         0              0




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

If the patient had an operative repair of pelvic fractures, was it completed > 6 hours after
arrival?


Exclusions: No operative repairs or patient
hemodynamically stable.
Inclusions: n = all patients with operative repair of
pelvic fractures with hemodynamic instability.

Indicator                Yes            No
                                                                               0.0
2007/2008, n = 0         0              0                                      0.0
                                                                             2007/2008


                                                                           %Yes      %No


  New indicator for 2007/2008.

  27. Definitive treatment of displaced acetabular fracture > 7 days of TCA.

If the patient had an operative repair of pelvic fractures, was it completed > 7 days of arrival?


Exclusions: No operative repairs or patient
hemodynamically unstable.
Inclusions: n = all patients with operative repair of
displaced acetabular fractures.

Indicator                Yes            No
                                                                               0.0
2007/2008, n = 0         0              0                                      0.0
                                                                             2007/2008


                                                                           %Yes      %No




  New indicator for 2007/2008.




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  28. Unplanned PICU admission or re-admission.

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


Exclusions: ED deaths.
Inclusions: n = all patients admitted to ACH
Trauma Centre.
                                                             99       100       100         97.8       100
Indicator                Yes            No

2007/2008, n = 89        0              89                                  0                                  0

2006/2007, n = 90        2              88                2003/2004 2004/2005 2005/2006 2006/2007 2007/2008

2005/2006, n = 86        0              86
                                                                            %Yes      %No
2004/2005, n = 83        0              83
2003/2004, n = 96        1              95




Did the patient have an unplanned readmission to ICU at the ACH trauma centre?


Exclusions: Patients without admission to ICU.
Inclusions: n = all patients with at least one ICU
admission.
                                                            100       100       100         98.2       100


Indicator                Yes            No                                                                     0
                                                             0         0         0          1.8
                                                          2003/2004 2004/2005 2005/2006 2006/2007 2007/2008
2007/2008, n = 49        0              49
2006/2007, n = 55        1              54                                  %Yes      %No

2005/2006, n = 44        0              44
2004/2005, n = 44        0              44
2003/2004, n = 52        0              52




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  Outcome:

  29. Death during the first 24 hours of TCA.

Did the patient die within the first 24 hours of admission to the ACH trauma centre?


Exclusions: All patients who survived.
Inclusions: n = all patients who died.                       28.6         30                                  33.3
Indicator             Yes              No                                                        42.9
                                                                                    57.1

2007/2008, n = 15        10            5
                                                             71.4         70                                  66.7
                                                                                    42.9         57.1
2006/2007, n = 7         4             3
2005/2006, n = 7         3             4                   2003/2004 2004/2005 2005/2006 2006/2007 2007/2008

2004/2005, n = 10        7             3
                                                                                 %Yes      %No
2003/2004, n = 7         5             2

  In 2007/2008 there were four patients with strangulation injuries, two patients with severe head
  trauma, two patients with drowning injuries and two patients with multiple injuries who died within
  24 hours. All deaths are reviewed by the Pediatric Trauma Clinical Safety Committee and the
  management of these cases was deemed appropriate.

  30. Did the patient die in ACH?

Did the patient die?


Exclusions: None.
Inclusions: n = all trauma patients arriving at ACH
trauma centre.
Indicator              Yes              No                   92.8         88.6      92.0         92.3         86.6

2007/2008, n = 97        13            84
                                                                                                                     13.4
                                                                    7.2          11.4      8.0          7.7
2006/2007, n = 91        7             84
                                                           2003/2004 2004/2005 2005/2006 2006/2007 2007/2008
2005/2006, n = 87        7             80
2004/2005, n = 88        10            78                                        %Yes      %No

2003/2004, n = 97        7             90

  In addition to the 10 patients who died within 24 hours in 2007/2008, an additional 3 patients died
  while hospitalized at ACH: one patient with drowning injuries, one patient with multiple injuries
  and one patient with a severe head injury. As above, these deaths are also reviewed by the
  Pediatric Trauma Clinical Safety Committee and their management was deemed appropriate.




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APPENDIX B
Major Trauma Statistics for 2007/2008


    1. General Overview
       Age
       Gender

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

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

    4. Patient Care Management
       Diagnostic Imaging Statistics
       Day of Week and Time of CT
       Non-Operative Procedures Performed in ED
       Surgical Procedures
       OR Data by Service
       Time to OR
       Length of Stay
       Admitting Physician Service
       Hospital Discharge Destination
       Outcomes by Age and ISS
       TRISS Pre-Charts




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1. General Overview

Table 1. ACH Major Trauma Statistics – Five-year Trend Analysis
Data Source: Alberta Trauma Registry at ACH

                                      2003/2004        2004/2005   2005/2006   2006/2007       2007/2008

Total Patients                              97               88          87          91                   97

Males                                        67               52          61          58                   54
                                         69.1%            59.1%       70.1%       63.7%                55.7%
Females                                      30               36          26          33                   43
                                         30.9%            40.9%       29.9%       36.3%                44.3%
Total Length of Stay (LOS) (days)          890              599         889         810                  943

Median LOS                                   5                5           5           5                    5

Mean LOS                                     9                7          10           9                   11

Total Emergency Department (ED) LOS       280.5            264.0       256.2       218.7               345.8
(hours)

Direct Admits                               14                9          15          10                    8

Median ED LOS (hours)                       3.6              3.3         3.0         2.7                  3.4

Mean ED LOS (hours)                         3.6              3.4         3.7         3.3                  3.9

ICU Admissions                               52               44          44          55                   49
                                         53.6%            50.0%       50.6%       60.4%                50.5%

Median ICU LOS (days)                        1                1           2           2                    2

Mean ICU LOS (days)                          3                2           4           4                    4

Total ICU LOS (days)                       176              106         178         218                  198

Median ISS                                  17               17          17          21                   24

Mean ISS                                   19.7             19.6        20.3        23.0                23.9

Referrals to ACH from other centres          47               33          42          43                   35
                                         48.5%            37.5%       48.3%       47.3%                36.1%
Deaths                                        7               10           7           7                   13
                                          7.2%            11.4%        8.0%        7.7%                13.4%



         In 2007/2008, 97 major trauma patients (meeting criteria for inclusion in the trauma
registry) were seen at the ACH. This volume is above the five-year average of 92 major trauma
patients seen annually. This 2007/2008 trauma volume represents 12.5% of all patients admitted
to the ACH with injuries (n=778), which is a 3% decrease from last year. As seen in previous
years, the percentage of major trauma patients who are males (55.7%) continues to be greater
than females, which is consistent with the five-year average of 63.5%. Major trauma patients
referred in from other centers represented 36.1% of the major trauma volume for 2007/2008.
This is lower than the five-year average of 44.5%.
         Length of stay for major trauma patients ranged between 1 and 98 days. Mean LOS of 11
days is greater than the five-year trend of 9.2. Median LOS of 5 days is consistent with the five-
year trend. The total ED LOS was 345.8 hours, up 58.1% from last year and higher than the five-
year average of 273 hours. Both the mean and median LOS was also slightly higher than the
five-year average.




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        There was a 7.6% drop in ICU admissions from 2006/07 to 2007/08. Overall, 50.5% of
major trauma patients were admitted to the ICU, which is lower than the five-year average of
52.6%. Total ICU LOS was 218 days, which is higher than the five-year average of 175. Median
and mean ICU LOS were higher with the five-year average of 1.6 and 3.4 respectively.
        Both the mean (23.9) and median (24) ISS for major trauma patient from 2007/2008 were
higher than the five-year averages of 21.3 (mean) and 19.2 (median). There was a 14.3%
increase in median ISS from 2006/2007 to 2007/2008. This is likely the reason for the increase in
LOS both in the ED and in the hospital in general and may be a contributing factor to the increase
seen in mortality as well.
        A total of 13 deaths were seen in major trauma patients in 2007/2008. This represents
13.4% of major trauma volume, and is greater than the five-year average of 8.6%.




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Figure 1. Age and Gender Distribution for ACH Major Trauma Patients for 2007/2008


                                        Age and Gender Distribution
                                                2007/2008

                   30
   # of Patients




                                                                          20
                   20                                                          14   13
                               10                         11
                                           8   6                 7                        6
                   10    2
                   0
                             <1             1-4                5-9        10-14      >14
                                                        Age Groups

                                                        Male     Female

       Figure 1 shows the number of males and females for the above age groups. On
average, males comprise 63.5% of the major trauma population over a period of five years.


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



                              15 to 17 year olds major trauma patients

                        50
                        40
   # of patients




                        30
                        20
                        10
                         0
                               2003/2004 2004/2005 2005/2006 2006/2007 2007/2008
                        ACH         17             16                20        13        19
                        FMC         40             33                39        39        37
                        PLC         1              2                 0         0         0
                        RGH         0              0                 0         0         0


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



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2. Etiology of Injuries

        Mechanism of Injury describes the nature of the injury, such as transportation, falls,
violence, and other mechanisms of injury.

Figure 3. Breakdown by Mechanism of Injury


                          2007/2008                                   2003/2004-2006/2007


                 Other                                             Other
                 24%                                               23%


                                                                                            Transport
                                                        Violence
      Violence                        Transport                                               46%
                                                          4%
        4%                              50%


                  Falls
                                                                    Falls
                  22%
                                                                    27%




       Figure 3 shows the breakdown of the mechanism of injuries for the incidents in
2007/2008 as compared to 2003/2004-2006/2007.

          In 2007/2008:
    •     Major cause of injuries were transportation-related incidents: 50%, n=49.
    •     Falls-related incidents: 22%, n=21.
    •     Assault and self-intentional harm comprised the violence-related incidents: 4%, n=4.
    •     Other mechanism of injury included animal-related incidents, accidental drowning, and
          mechanical-related incidents: 24%, n=23. Struck by falling object, striking against/by
          objects or persons in sports or non-sports, caught between objects, or contact with
          cutting tools are some examples of mechanical-related incidents.




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Mechanism of Injury – Transportation

Figure 4. Transportation Statistics


                             2007/2008                                    2003/2004-2006/2007
                                Water
                                                                                  Water   Railw ay
                                 0%
                                                                                   1%       0%
                                        Railw ay

                     MRV                  0%
                                                                            MRV
                     12%                                                     11%


     Cy clist                                      MVC
                                                              Cy clist                                MVC
       20%                                         46%
                                                               24%                                     46%




                Pedestrian                                               Pedestrian
                   22%                                                      18%



      Figure 4 shows the breakdown of transportation-related injuries in 2007/2008 as
compared to 2003/2004-2006/2007.

         In 2007/2008:
          Major causes of injuries were due to motor vehicle collisions (MVC): 46%, n=22.
          Pedestrians: 22%, n=11.
          Cyclists include pedal cyclists, or bicyclists: 20%, n=10.
          Motorized Recreational Vehicle (MRV) includes all-terrain vehicles (ATV), snowmobiles:
          12%, n=6.
          Water includes motorized vehicles used for water transport: 0%, n=0.
          Railway includes collisions with the train: 0%, n=0.

        A total of 49 patients (50.5% of major trauma patients) were involved in transportation-
related incidents in 2007/2008.
         Mortality: 10% (n=5) did not survive.
         ISS ranged from 13 to 57.
         For survivors, both mean and median ISS was 25.
         For non-survivors, mean ISS was 26 and median ISS was 25.




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


                                         MOI - Transportation

                   50                                                             49

                   48
   # of patients




                   46

                   44       43                                      43

                   42                     41             41

                   40
                         2003/2004     2004/2005     2005/2006   2006/2007   2007/2008


       Figure 5 shows the 14% increase in transportation-related incidents from 2006/2007 to
2007/2008.

Figure 6. Transportation by Age Group


                             2007/2008                               2003/2004-2006/2007

                                  <1    1-4                                  <1
                                                                    >14                1-4
                   >14            0%   10%                                   0%
                                                                    18%                16%
                   24%

                                                   5-9
                                                   22%                                          5-9
                                                                                                18%




                                                                    10-14
                          10-14
                                                                     48%
                           44%




      Figure 6 shows the breakdown of transportation incidents by age groups in 2007/2008 as
compared to 2003/2004-2006/2007.

In 2007/2008:
    Age Group 1-4 (n=5, 10%) included 3 passengers, and 2 pedestrians.
    Age Group 5-9 (n=11, 22%) included 8 passengers, 1 bicyclist, and 2 pedestrians. There
    were 3 deaths in the age category.
    Age Group 10-14 (n=21, 44%) included 7 bicyclists, 5 passengers, 4 pedestrians, 3 drivers,
    and 2 motorcyclists. There were 2 deaths in this age category.



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     Age Group > 14 (n=12, 24%) included 6 passengers, 2 bicyclists, 2 pedestrians, and 2
     motorcyclists.




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Mechanism of Injury – Falls

Figure 7. Statistics for Falls as the MOI


                      2007/2008                                        2003/2004-2006/2007


                                                                       Other &
          Other &
                                                                     Unspecified
        Unspecified
                                                                        10%
           24%

                                                       Same lev el
                                                          26%

     Same level                     Multi-level
                                                                                             Multi-lev el
        14%                           62%                                                       64%




       Figure 7 shows the breakdown of falls incidents in 2007/2008 as compared to 2003/2004-
2006/2007.

      In 2007/2008, multi-level falls accounted for 62% (n=13) of falls. Other/unspecified falls
and same level falls accounted for 14% (n=3) and 24% (n=5) respectively.

         A total of 21 patients (21.6% of major trauma patients) were admitted for falls-related
injuries.
          Mortality: 0%: All patients survived.
          ISS ranged from 14 to 50.
          Mean ISS was 22 and the median ISS was 18.




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                    Figure 8. Five-Year Trend for Falls as the MOI


                                                MOI - Falls

                   30       27                          27
                                           25
                   25                                                                  21
                                                                        18
                   20
   # of patients




                   15

                   10

                    5

                    0
                         2003/2004     2004/2005    2005/2006        2006/2007    2007/2008



                    Figure 8 shows an increase of 16.7% in falls from 2006/2007 to 2007/2008.

Figure 9. Falls by Age Group


                                 2007/2008                                        2003/2004-2006/2007


                          >14                                                                       <1
                                                                                 >14
                          14%                                                                      13%
                                                                                 21%

            10-14                                     <1
            10%                                      38%


                                                                                                          1-4
                   5-9                                                   10-14                           28%
                   14%                                                    19%


                                     1-4                                                     5-9
                                     24%                                                    19%




       Figure 9 shows the breakdown of falls incidents by age groups in 2007/2008 as compared
to 2003/2004-2006/2007. The biggest change was an increase in the <1 yr old population.

In 2007/2008:
    Age Group <1 (n=8, 38%) included 6 multi-level falls, 1 fall on or from stairs/steps, and 1
    other and unspecified fall.
    Age Group 1-4 (n=5, 24%) included 2 falls on or from stairs/steps, 1 multi-level fall and 2
    other and unspecified falls.
    Age Group 5-9 (n=3, 14%) included 2 falls on same level and 1 other and unspecified fall.
    Age Group 10-14 (n=2, 10%) included 1 multi-level fall and 1 fall on or from stairs/steps.
    Age Group > 14 (n=3, 14%) included 2 falls on same level and 1 multi-level fall.


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     Mechanism of Injury – Violence

Figure 10. Violence as the MOI


                      2007/2008                                       2003/2004-2006/2007

                           Unarmed
                                                                        Other &
         Other &           assault    Assault
                                                                      Unspecified
       Unspecified           0%      w ith object                                            Unarmed
                                                                         13%
          25%                            0%                                                    assault
                                                                                                31%



                                                           Self-
                                                          inflicted
                                                           31%
                                       Self-
                                                                                     Assault
                                      inflicted
                                                                                    w ith object
                                       75%
                                                                                       25%




       Figure 10 shows the breakdown of violence-related incidents in 2007/2008 as compared
to 2003/2004-2006/2007.

        In 2007/2008, violence-related incidents were comprised of self-inflicted 75% (n=3), and
other/unspecified assault 25% (n=1). Small numbers account for the large percentage differences
when comparing years.

         A total of 4 patients (4% of major trauma patients) were admitted for violence-related
injuries.
          Mortality: 25% (n=1) survived and 75% (n=3) did not survive.
          ISS ranged from 16 to 25.
          For survivors, both mean and median ISS was 16.
          For non-survivors, mean ISS was 22 and median ISS was 25.




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Figure 11. Five-Year Trend for Violence as the MOI


                                             MOI - Violence

                   8       7
                   7
                   6                     5
   # of patients




                   5                                                                 4
                   4                                                 3
                   3
                   2                                   1
                   1
                   0
                       2003/2004    2004/2005     2005/2006      2006/2007     2007/2008



        Figure 11 shows the overall downward trend from 2003/2004 to 2007/2008 but an
increase over the past few years.

Figure 12. Violence Incidents by Age Group


                               2007/2008                                        2003/2004-2006/2007

                                   >14
                                   0%             <1
                                                                                                       <1
                                                 25%                     >14                          25%
                                                                         30%


                                                          1-4
                                                          0%

                                                    5-9                                                  1-4
                                                    0%                                                  13%
                   10-14
                   75%                                                       10-14             5-9
                                                                              19%              13%




      Figure 12 shows the breakdown of violence incidents by age groups in 2007/2008 as
compared to 2003/2004-2006/2007.

        Age Group <1 (n=1, 25%) include one suspected child abuse resulting in death.
        Age Group 10-14 (n=3, 75%) included 3 hanging injuries, 2 of which died.




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Mechanism of Injury – Other

Figure 13. Statistics for Other Mechanism of Injury


                       2007/2008                                            2003/2004-2006/2007

                           Other &                                                Other &

       Submersion      Unspecified                             Submersion        Unspecified   Animal
                           0%        Animal                                          1%         14%
          26%                         26%                              13%                               Fire &
                                                                                                        Explosion
                                                                                                          11%

                                               Fire &
                                              Explosion                                                  Inhalation

                                                 4%                                                     & Ingestion
                                                                                                           10%
                                            Inhalation
                Mechanical                                          Mechanical
                                         & Ingestion
                  40%                                                 51%
                                                4%




      Figure 13 shows the breakdown of other mechanism of injuries in 2007/2008 as
compared to 2003/2004-2006/2007.

        In 2007/2008, other mechanism of injuries included: animal-related incidents 26% (n=6),
fire & explosion 4% (n=1), inhalation & ingestion 4% (n=1), submersion & drowning 26% (n=6),
and mechanical-related incidents 40% (n=9). Struck by a falling object, striking against/by objects
or persons in sports or non-sports, caught between objects, or contact with cutting tools are some
examples of mechanical-related incidents.

        Submersion & drowning mechanisms as well as animal related injuries were increased
this year. In turn, note the decrease of fire & explosion (including electrical) and inhalation &
ingestion mechanisms in 2007/2008.

         A total of 23 patients (24% of major trauma patients) were admitted for other mechanism
of injuries.
          Mortality: 78% (n=18) survived and 22% (n=5) did not survive.
          ISS ranged from 16 to 50.
          For survivors, both the mean and median ISS was 25.
          For non-survivors, mean ISS was 21 and median ISS was 25.




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


                                                   MOI - Other

                   30                                                       27
                                                                                            23
                   25
                                 20
                                                           18
                   20                         17
   # of patients




                   15

                   10

                    5

                    0
                           2003/2004       2004/2005    2005/2006        2006/2007       2007/2008



         Figure 14 shows a decrease in the number of patients whose injuries are caused by
animal, burn, inhalation, accidental drowning, and mechanical-related incidents when compared
to last year.

Figure 15. Other Mechanism by Age Group


                                      2007/2008                                          2003/2004-2006/2007
                                                                                                     <1
                                                   <1                                    >14
                           >14                                                                       2%
                                                  13%                                    15%
                           17%
                                                                                                                 1-4
                                                                                                                 28%
                                                          1-4
                                                          17%




                   10-14                                                         10-14
                   36%                                                            38%
                                                    5-9                                                        5-9
                                                    17%                                                        17%




       Figure 15 shows the breakdown of incidents involving other mechanism of injury by age
groups in 2007/2008 as compared to 2003/2004-2006/2007.

In 2007/2008:
    Age Group <1 (n=3, 13%) included 3 accidental drowning/submersions.
    Age Group 1-4 (n=4, 17%) included 1 machinery accident, 1 accidental drowning, 1 caught in
    or between objects and 1 animal injury.
    Age Group 5-9 (n=4, 17%) included 1 accidental drowning, 1 striking against objects or
    persons in sports, and 2 animal-related injuries. There were 3 deaths in the age category.


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          Age Group 10-14 (n=8, 36%) included 4 striking against objects or persons in sports, 2
          animal-related injuries, 1 struck by a falling object and 1 accidental drowning. There were 2
          deaths in the age category.
          Age Group >14 (n=4, 17%) included 1 animal-related injury, 1 clothing ignition incident, 1
          foreign body injury, and 1 striking against objects or persons in sports.

Type of Injury

        Type of Injury indicates whether the most serious injury is blunt, penetrating, burn, or
other type of injury (strangulation, hanging and drowning).

Figure 16. Type of Injury


                                       Type of Injury - 2007/2008
                                            Total Pts = 97

   100                    84
       80
       60
       40
       20                                                                               11
                                               1                    1
             0
                         Blunt           Penetrating               Burn                Other

        Figure 16 shows the different types of injuries sustained by the major trauma patients in
2007/2008. Blunt injuries comprised 86.6% of major trauma population. Other type of injury
(11.3%) includes drownings and hangings, while penetrating injuries and burn comprised 1%
each of the major trauma patients.

Figure 17. Five-Year Trend for Type of Injury


                                      Type of Injury - Five Year Trend
                                               Total Pts = 460

                   100   87             81                                85              84
                                                        76
   # of Patients




                   50
                                                                                                     11
                              1 1 8          2 0 5           1 4 6             2 0 4           1 1
                    0
                         2003/2004       2004/2005      2005/2006         2006/2007       2007/2008
                                                       Fiscal Years

                                             Blunt   Penetrating     Burn      Other


Figure 17 compares the different types of injuries from 2003/2004 up to 2007/2008.




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Place of Injury


Figure 18. Statistics for Place of Injury


                            2007/2008                                          2003/2004-2006/2007

                 Unspecified                                                                       Home/Res
                                  Farm                                                      Farm
                     9%                                                                              Inst
                                  8%                                                        2%       20%

                                                     Home/Res        Unspecified
                                                                                                        Other
                                                        Inst            33%
                                                                                                            2%
        Street
                                                        26%
        31%                                                                                                 Public
                                                                                                        Building
                                                                                                             4%
                                                    Other
                                                                                                     Recreation
                   Recreation             Public 3%
                                                                                   Street              14%
                      16%                Building
                                                                                   25%
                                           7%




       Figure 18 shows where the patients were injured in 2007/2008 as compared to
2003/2004-2006/2007. Some places of injury saw a large change in 2007/2008 due to a more
thorough chart auditing process.

            In 2007/2008:
    •       Most injuries were sustained in the streets (31% n=30) and at home/residential
            institutions (26% n=25).
    •       Sixteen percent of patients (n=15) were injured in recreational areas.
    •       Due to the lack of documentation, a total of 9 (9%) places of injury were not identified at
            the time of this publication.
    •       Seven percent (n=7) of incidents occurred in public buildings, 8% (n=8) happened in
            farms, and 3% (n=3) took place in other specified places of injury.




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3. Referrals to ACH

Referral Patterns

         Out of 460 major trauma patients from 2003/2004 to 2007/2008, a total of 201 patients
(43%) were referred to ACH by other hospitals.
         The highest number of referrals to ACH was made by Lethbridge Regional Hospital with a
total of 15 patients (7.5% of total referrals) over five years. Red Deer Regional ranked second
with a total of 13 patients (6.5%) referred.

Table 2. Transfers from Other Centres by Health Region

 Region       Hospital                            2003/2004   2004/2005   2005/2006   2006/2007   2007/2008   Total


 Region 1 - Chinook Health Region, Total = 39
              Blairmore - Crowsnest Pass                1                                1           1         3
              Cardston - Blood Indian                                        1                                 1
              Cardston - Municipal                               1                       3           1         5
              Fort Macleod H.C.C.                                                        1                     1
              Lethbridge Regional                       4        4           2           1           4         15
              Milk River                                1                                            1         2
              Pincher Creek Municipal                   1        1                       1           3         6
              Raymond General                                                            1                     1
              Taber H.C.C.                              1                    2           2                     5


 Region 2 - Palliser Health Region, Total = 15
              Bassano General                                                1                                 1
              Bow Island General                                                                     1         1
              Brooks Health Centre                               2           3           2                     7
              Medicine Hat Regional                     2                    1                       1         4
              Oyen - Big Country                                 1                                   1         2


 Region 3 - Calgary Health Region, Total = 61
              Banff - Mineral Springs                   3        1           4           1           1         10
              Black Diamond - Oilfields General                                          2                     2
              Calgary - Foothills                       2        1                       2           1         6
              Calgary - General/Peter Lougheed          3        2           2           1           3         11
              Calgary – Rockyview General               1        1           2           1                     5
              Canmore General                           1        1           1           1           2         6
              Claresholm General                                 1           1                       1         3
              Didsbury - Mountain View H.C.                      1                       4                     5
              High River General                        5        1                       1           1         8
              Strathmore - Valley General               1                    1                                 2
              Vulcan General                                     1                                   2         3




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 Region       Hospital                                  2003/2004   2004/2005   2005/2006   2006/2007   2007/2008   Total


 Region 4 - David Thompson Health Region, Total = 45
              Castor - Our Lady of the Rosary                                                  1                     1
              Coronation Municipal                           1                                                       1
              Drumheller Regional                            1         1                       4                     6
              Hanna H.C.C.                                   1                     1                                 2
              Innisfail H.C.C.                               2         1           1                                 4
              Olds General                                   1         1                                             2
              Red Deer Regional                              1         2           1           8               1     13
              Rocky Mountain House                           6                     2                                 8
              Stettler General                                         2                                             2
              Sundre General                                 1                                                       1
              Three Hills H.C.C.                             1                     2                           2     5


 Other Alberta Hospitals, Total = 1                                                1                                 1


 British Columbia, Total = 39
              Cranbrook Regional Hospital                    3         1           2           1               2     9
              Creston Valley Hospital                                              2           1                     3
              Fernie District Hospital                       1                     1           2                     4
              Golden & District General Hospital                       1           2                           2     5
              Invermere District Hospital                    1         1           3                           2     7
              Nelson, Kootenay Lake District Hospital                              1                                 1
              Penticton Regional Hospital                                                      1                     1
              Revelstoke, Queen Victoria Hospital                      1                                             1
              Salmon Arm, Shuswap Hospital                             1                                       1     2
              Sparwood, Sparwood General Hospital                      1                       1               1     3
              Other BC Hospitals                             1         1           1                                 3


 Saskatchewan, Total = 1
              Lloydminster General                                                 1                                 1




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Mode of Transport for Patients Arriving at ACH

Figure 19. Direct from the Scene


                           2007/2008                                  2003/2004-2006/2007
           Priv ate/                                                     Priv ate/    Other
                                  Other
            Walk-in                                                      Walk-in      0.0%
                                   0%
             26%                                                           22%

                                                                Fix ed-
           Fix ed-                                               w ing
            w ing                                                0.5%
            0%                                  Ground        Helicopter                         Ground
         Helicopter                              63%            13%                               64%
            11%




      Figure 19 shows the patients arriving at ACH-ED directly from the scene in 2007/2008 as
compared to 2003/2004-2006/2007.

    •      In 2007/2008, 63% of patients (n=39) arrived directly from the scene by ground
           ambulance, 26% of patients (n=16) used private vehicle or walked into the ED.
           Helicopter ambulance brought 11% of patients (n=7) directly to the ED.

Figure 20. Referrals


                           2007/2008                                  2003/2004-2006/2007
                       Priv ate
                                        Other                              Priv ate
                       v ehicle                                                         Other
         Fix ed-                          0%                           v ehicle
                         3%                                      Fix ed-                  1%
          w ing                                                           2%
                                                                  w ing
          20%
                                                                   21%

                                                                                                Ground
                                                Ground                                           47%
                                                 54%

        Helicopter
          23%                                                  Helicopter
                                                                  29%



      Figure 20 shows the patients who were referred to ACH for further treatment in 2007/2008
as compared to 2003/2004-2006/2007.

    •      In 2007/2008, 54% of patients (n=19) were brought in by ground ambulance, 23% of
           patients (n=8) were transported by helicopter and 20% (n=7) by fixed-wing. Three
           percent (n=1) were transferred via private vehicle or walked into ACH-ED.



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Figure 21. Ground vs Air


                                       Five-Year Trend

                   70      60                                               58
                                       52                     54
                   60
                   50                            40
   # of patients




                   40
                   30
                                                 33
                   20      26          26                     24            22
                   10
                   0
                        2003/2004 2004/2005 2005/2006 2006/2007 2007/2008

                                             Ground       Air


        Ground ambulance transported 58 patients (59.8%) of major trauma patients in
2007/2008, a 7.4% increase from the previous fiscal year. Figure 21 shows the decrease in the
use of air transport by 8.3% in 2007/2008.


Month and Time of Arrival


Figure 22. Month of Arrival


                             Comparison of ED Arrival by Month for 2007/2008 with
                                            2003/2004-2006/2007

                                20.0
                                15.0
                                10.0
                                 5.0
                                 0.0
                                       Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
               Mean 03/04-06/07 6.5 6.8 7.8 11.8 13.5 6.8 8.8 5.0 7.0 5.8 5.5 5.8
               2007/2008                6    7    11     16     8       7        9   6   6   11   5   5


        There was an increase in major trauma patients arriving in ACH-ED for 7 out of 12
months in 2007/2008, as compared to 2003/2004 to 2006/2007 data. The highest percent
increase of 90% was seen in January, while the biggest drop was seen in August, with a percent
decrease of 41%.




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Figure 23. Day of Arrival


                                Comparison of Arrival by Day
                           for 2007/2008 with 2003/2004-2006/2007

                  20.0


                  10.0


                    0.0
                             Sun     Mon     Tue    Wed     Thu     Fri    Sat

     Mean 03/04-06/07        15.5    12.3    12.0   13.8    11.5    10.3   15.5
     2007/2008                15     15       7      11      14     19     16



        In 2007/2008, there was an increase in major trauma patients arriving in ACH-ED on
Mondays, Thursdays, Fridays and Saturdays. The days of Sunday, Tuesday, and Wednesday
were less busy in 2007/2008 compared to the previous years.




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Time of Arrival

Figure 24. Time of Arrival


                           Comparison of Time of Arrival
                      for 2007/2008 with 2003/2004-2006/2007
                                                                              13.5%

                     80.0
                                                             8.5%
                     60.0
                                          23%
                     40.0
                     20.0
                       0.0
                                 00:01-08:00       08:01-16:00         16:01-24:00
      Mean 03/04-06/07              13.0                25.8               52.0
      2007/2008                      10                 28                  59


         Figure 24 shows a decrease of 23% for patients arriving at ACH-ED from past midnight to
8:00 in the morning. There is an 8.5% increase of patients arriving at ACH-ED between 8:01 and
16:00 in 2007/2008. More patients arrived from 16:01 to midnight in 2006/2007 (13.5%)
compared to the past four years.


Figure 25. Time of Arrival of Patients Arriving Directly from the Scene


            Comparison of Patients Arriving Directly from the Scene
                   for 2007/2008 with 2003/2004-2006/2007
                                                                                 40.3%
                       60.0
                                                               2.7%
                       40.0               51.5%

                       20.0

                           0.0
                                  00:01-08:00       08:01-16:00        16:01-24:00
      Mean 03/04-06/07                3.3               18.5               27.8
      2007/2008                           5              18                 39




          Figure 25 shows the patients that arrive at ACH directly (without going to another medical
facility) and shows the same pattern as in Figure 24. There is a 51.5% increase of patients
arriving directly from the scene from past midnight to 8:00 in the morning, a 2.7% decrease from
8:01 to 16:00, and a 40.3% increase from 16:01 to midnight.


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Patient Disposition from ED

Figure 26


                      2007/2008                                   2003/2004-2006/2007

                              Died in ED                                  Died in ED
                                    8%                                       2%


         Ward
                                                         Ward
          40%
                                                         43%
                                                                                        ICU
                                           ICU                                          49%
                                           43%
        Other
         0%                                                Other
                           OR/ICU                           0%
          OR/Ward                                                         OR/ICU
                            6%                                  OR/Ward
                3%                                                         4%
                                                                  2%




      Figure 26 shows the breakdown of patient disposition from the ED in 2007/2008 as
compared to 2003/2004-2006/2007.

       In 2007/2008, a high percentage of patients (42%, n=41) were admitted to ICU post ED,
while 6% were admitted to ICU post surgery. A total of 39 patients (40%) were admitted to a unit
post ED. There were eight ED deaths for this period.




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4. Patient Care Management

Diagnostic Imaging Performed-2007/2008

Table 3. Diagnostic Imaging

         A total of 73 patients (75.3% of major trauma patients) went urgently to CT for imaging of
the following body locations. An additional two patients went to CT non-urgently.

                   Diagnostic Imaging CT      # Patients        Percent of Total Patients
                        Locations                                        (n=73)
 Head                                            58                       79%
 Abdomen                                         42                       58%
 Pelvis                                          41                       56%
 Chest                                           24                       33%
 Spine                                           22                       30%
 Face                                            3                         4%

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


Figure 27. Time of CT


                        Time of Urgent CT (within 6 hours of arrival, n=73)

                   70                                                     58
                   60
   # of Patients




                   50                                                           45
                   40
                   30                                      19
                   20         8      9           11
                   10
                    0
                             00:01-08:00        08:01-16:00              16:01-24:00
                                               Time of Day

                                            2006/2007      2007/2008


         Figure 27 compares the time of urgent CTs from 2006/2007 to 2007/2008. In 2007/08,
61.6% (n=45) of patients who went to CT had CTs done from 16:01 to midnight. Only 12.3% of
patients had CT’s from midnight to 8:00 AM, and 26% of patients had CT’s from 08:01 to 16:00.




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Figure 28

                                       Day of the Week CT performed

                   20                         17                           16    15
                   15
   # of Patients




                             12                           12
                                                                                             11
                        10                         10          10                      10         9
                   10              7   6
                                                                       5
                    5

                    0
                        Monday    Tuesday   Wednesday    Thursday      Friday    Saturday    Sunday

                                                   2006/2007     2007/2008


         Figure 28 compares the day of the week CT was performed from 2006/2007 to
2007/2008. The Diagnostic Imaging department has extended their hours to include evenings, but
at this point in time, the ACH does not have an in-house CT tech on weekend days. Due to the
large numbers of urgent CTs required on the weekends, it is expected this support will be in place
within the next fiscal year.

Non-Operative Procedures Performed in 2007/2008


Table 4. Non-operative Procedures Performed on Patients while in ACH-ED.

  Non-Operative Procedures                  # Patients    Percent of Total Patients (n=97)



 Gastric Tube Insertion                        26                          27%
 Foley Catheter Insertion                      25                          26%
 Intubation                                    12                          12%
 Blood Product Administration                   7                           7%
 Chest Tube Insertion                           5                           5%
 Central Line                                   4                           4%



Surgical Procedures

Table 5. Five-Year Trend

                                              2003/2004        2004/2005   2005/2006    2006/2007     2007/2008
 Total Major Trauma Patients                         97               88          87           91             97
 Total Patients Requiring Surgery                    31               34          28           24            28
 Total OR Visits                                     37               48          59           30            53
 Total OR Hours                                      80              101         112           72           129
 Mean (hours per case)                              2.6              3.0         4.0          3.1            4.6
 Mean (visits per case)                             1.2              1.4         2.1          1.3            1.9



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Figure 29


                                    Total Patients Requiring Surgery

                   40                    34
                   35      31
                                                       28                        28
                   30                                                  24
   # of patients




                   25
                   20
                   15
                   10
                   5
                   0
                        2003/2004    2004/2005     2005/2006      2006/2007   2007/2008


         In 2007/2008, a total of 28 (29%) patients required surgery during the patient’s stay in the
hospital. Table 6 shows the physician services that performed the surgical procedures. During
some procedures, there were multiple physician services in the OR at one time.


Table 6. OR Data by Service


 OR Data by Service - 2007/2008

 Physician Service                               # of Procedures
 Neurosurgery                                            6
 Orthopedics                                            15
 Pediatric Surgery                                      13
 Plastics                                               25
 Interventional Radiology                                3
 Otolaryngology                                          5
 Cardiology                                              1




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Figure 30. Time to OR


                                                       Time to OR

   16                                                      14
   14                                                                           12
   12                                                                      11
                                                     10
   10
                                                                                            2006/2007
          8
                                                                                            2007/2008
          6
          4                       3
                                       2
          2
          0
                             00:00 - 08:00         08:01 - 16:00      16:01 - 23:59


        Figure 30 compares the time patients went to the OR in 2006/2007 with 2007/2008. In
2007/2008, out of the 28 patients who went to OR, eleven were urgent OR cases and all except
two were done between 16:01and 23:59. The remainder two had one case in each of the other
time frames.

Length of Stay Statistics


Figure 31. Patient LOS


                                                  LOS by Percentile of Patients

                            40%       36%
   Percentile of Patients




                            35%             34%
                            30%                   26% 27%
                            25%
                                                                20% 20%         19%                     2006/2007
                            20%                                                       15%               2007/2008
                            15%
                            10%
                                                                                                 4%
                             5%                                                             0%
                             0%
                                       1-3           4-6           7-12         13-60       61-98
                                                           Number of Days

        Figure 31 compares the LOS of patients from 2006/2007 to 2007/2008. In 2007/2008, the
median LOS for all patients is 5 days. A majority of patients (61%) stayed between 1 and 6 days,
while 35% of patients stayed between 7 and 60 days.




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Admitting Physician Service Analysis – 2007/2008

Table 7

   Physician          # Patients   Percent of    # Patients      Total       Total      Mean      Median
    Service            Initially     Total      Transferred     Trauma       Days      LOS on     LOS on
                     Admitted to    Patients     to Service      Cases        on       Service    Service
                       Service     Admitted                       per       Service
                                     n=89                       Service

 ICU                         48        53.9%               0          48        198         4.1        2.0
 Neurosurgery                 9        10.1%               3          12         56         4.7        3.5
 Orthopedics                  2         2.2%               1           3         11         3.7        3.0
 Pediatric
 Surgery                     19        21.3%              25          44        378        8.8         6.0
 Pediatrics                  10        11.2%              12          22        269       11.7         3.0
 Plastics                     1         1.1%               0           1         17       17.0        17.0
 Other
 (Cardiology)                  0        0.0%               1            1          9        9.0        9.0

 Total                       89                           42         131        938

           In 2007/2008, a total of 48 patients (53.9%) were admitted to ICU. Out of those patients
initially admitted to ICU,
           25 patients were transferred to Pediatric Surgery,
           12 patients went to Pediatrics,
           3 patients went to Neurosurgery,
           1 patient went to Orthopedics,
           1 patient went to Cardiology,
           5 patients died, and
           1 patient was transferred out of the region.




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Hospital Discharge Destination

Figure 32. Discharge Destinations


                  Comparison of Discharge Destination for 2007/2008 with
                                  2003/2004-2006/2007

                  100

                   80

                   60

                   40

                   20

                    0
                           Another     Children's                       Home w ith                Rehab
                                                          Died   Home                Other
                         Acute Care Aid/Foster                           Support                  Facility

      Mean 03/04-06/07       3            1.5             7.75    77       1.25      0.25            0

      2007/2008              1             1               13     81        0          1             0



       Figure 32 shows a 5.2% increase in the number of patients discharged home and a
67.7% increase in deaths in 2007/2008 as compared to 2003/2004-2006/2007.

Outcomes by Age


Figure 33. Survivors


                   Comparison of Survivors by Age Group for
                     2007/2008 with 2003/2004-2006/2007

                  40.0

                  30.0

                  20.0
                  10.0

                   0.0
                                 <1                 1-4          5-9        10-14            > 14
     Mean 0304-0607              4.8                16.0         13.5        33.0            15.8
     2007/2008                   9                  12           14             30           19



         Figure 33 shows an increase in survivors for age group <1 at 87.5%, age group 5-9 at
3.7%, and >14 at 5.3%. Other age groups showed a decrease in the number of survivors by 25%
(1-4), and 9.1% (10-14).




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Figure 34. Non-Survivors


                        Comparison of Non-Survivors by Age Group for
                            2007/2008 with 2003/2004-2006/2007

                             6.0

                             4.0

                             2.0

                             0.0
                                   <1            1-4               5-9       10-14      > 14
          Mean 0304-0607           0.8            3.0               2.0       1.3        0.8
          2007/2008                 3             2                 4          4          0



        Figure 34 shows a 33.3% decrease in age group 1-4 and 100% in age group >14, while
the other age groups experienced an increase in the number of non-survivors: 275% (<1), 100%
(5-9), and 207.8% (10-14).


Outcomes by ISS – 2007/2008


Figure 35. Survivors vs Non-Survivors by ISS


                                               2007/2008

                   60              52
                   50
   # of patients




                   40
                   30                            21
                   20                    11
                   10    5                                         3 2       2 0
                              0                         0                              1 0
                    0
                        12 - 15    16 - 25      26 - 35           36 - 45   46 - 55   56 - 65
                                                            ISS

                                              Survivors      Non-Survivors


       Most survivors (61.9%, n=52) had ISS from 16 to 25. Mortality rate was highest in the
ISS range 16-25 with 17.5% death rate, followed by ISS 36-45 with 8.9% mortality rate.




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TRISS Pre Charts for 2007/2008

         The following charts identify patients according to their probability of survival (Ps). Each
patient is characterized by the Revised Trauma Score (RTS) and the Injury Severity Score (ISS)
and then plotted on a graph.

        The shaded area represents the combination of the RTS and the ISS which yield a
probability of survival (Ps) of >.50. The area above the line represents a probability of survival of
<.50. Patients who are above the shaded area and survive and those who die and are plotted in
the shaded area are atypical cases and subject to medical review. The age groups are standard
age groups used in the development of the TRISS analysis.

Figure 36. Pediatric Pre Charts include blunt and penetrating mechanisms for patients < 15
years.




        There was one unexpected death and one unexpected survivor for patients less than 15
years in 2007/2008 using the TRISS methodology. The unexpected death was reviewed at the
Pediatric Trauma Clinical Safety Committee, as well as at Mortality and Morbidity rounds, and
management was deemed appropriate.



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Figure 37. Adult Pre Charts include patients between 15 and 17 years who sustained a blunt
injury.




       There were no unexpected deaths and no unexpected survivors for patients between 15
and 17 years in 2007/2008 using the TRISS methodology.




                                              111
Trauma Statistics &
Performance/Outcome
Data
PETER LOUGHEED CENTRE
ROCKYVIEW GENERAL HOSPITAL
Regional Trauma Services                                                                                  2007/2008
PLC & RGH – Trauma Statistics & Performance/Outcome Data



TRAUMA SUMMARY FOR PETER LOUGHEED (PLC)

April 1, 2007 – March 31, 2008

Capturing the major trauma population at the PLC is based on a review of the monthly injury
discharges prepared by Quality Safety Health Information (QSHI). Trauma patients with an Injury
Severity Score (ISS) ≥12 were identified through chart audit.

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 (ATR) ranges between 12 and
75; the higher the ISS, the more serious the injury.

Patients that are admitted to the hospital with a trauma-related mechanism of injury and any of
the following injuries prompts a chart audit:
       - head injury and or comatose/unspecified comatose;
       - rib fracture > 1 or unknown with pneumothorax/hemothorax;
       - multiple body regions injury;
       - abdominal injury;
       - spinal injury;
       - any significant mechanism of injury (cause)
       - Emergency Department deaths

Staff is encouraged to complete a trauma follow-up form in the Emergency Department with
information on the traumatically injured patient. Forms were collected on a regular basis. System
issues were referred directly to Regional Trauma Services.

The following reports reflect the major trauma population (ISS ≥12) that was identified and
reviewed by Trauma Services, based on the evaluation process list identified above.


Yearly Major Trauma Totals
                                                      35         The PLC five year trend demonstrates a
                                                                 decrease from 2003/2004 to 2004/2005 (45.4%),
     22
                             20
                                         22                      an increase from 2005/2006 (50%), an increase
                                                                 in 2006/2007 (4.4%) and a significant increase in
                  10                                             2007/2008 (62.8%).
                                                                 The numbers do not reflect the patients that
                                                                 arrived in ED and were transferred to Trauma
  2003/2004    2004/2005   2005/2006   2006/2007   2007/2008
                                                                 Centres.


ISS Scores 2007/2008

              Range: 13-24 Average: 18                     Median: 16




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Monthly Major Trauma Totals
                                                       2007/2008                                                                                                                 2006/2007

                                                                        7
                                                                                                                                                                           4
   # of patients




                                                                                                                                         # of patients
                                                        5                        5                                                                       3     3                             3

                            3                                    3                                             3                                                                                         2     2     2
                       2             2         2                                            2
                                                                                                                                                                                  1    1           1
                                                                                                                      1
                                                                                                    0                                                                0                                                     0

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




 These graphs demonstrate the unpredictable nature of trauma at this site. The numbers do not
 reflect the patients that arrived in ED and were transferred to the Trauma Centres.


 Males/Female – 2007/2008

                                                                                       26

                                                                                                                                         Males continue to outnumber females at the
                                                                                                                                         PLC, a ratio of 2.89:1.
                           14

                                                                                                          9
                                           8




                           2006/2007                                                 2007/2008

                                                       Males           Females




 Age Distribution – 2007/2008
                                                                  9
                                                                                                                                         In 2007/2008, the majority of the population
                                                                                                                                         was between 45-64 and >84.
                                                             7                                                              7 7



                                                                                                5

                                                                                                              4 4

                                 3                                               3

                   2                               2                                        2

             1                             1

                            0                                                0

           18-24            25-34          35-44             45-54          55-64           65-74             75-84         > 84


                                                        2006/2007       2007/2008




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Mechanism of Injury (MOI) – 2007/2008

                                                        21                                                 The MOI is reported by four broad
                                                                                                           categories: transportation, falls, violence
                                                   16
   # of patients

                                                                                                           and other. These are in keeping with the
                                                                                                           focus of the Calgary Health Region’s injury
                                                                                                           control initiatives. Falls continue to be the
                                 6
                                                                      5       5                            number one mechanism of injury at the
                                                                                                3
                             1                                                                             PLC.
                                                                                           0

                    Transportation                  Falls             Violence              Other


                                                 2006/2007           2007/2008


Mode of Arrival – 2007/2008

                        21
                                 19                                                                       For the fiscal year 2007/2008, PLC has
                                                                16                                        been receiving a significant number of
                                                                                                          patients that are arriving in ER department
                                                                                                          via private vehicle/walk-in.
                                                                                                          In 2006/2007 only 4.5% of patients arrived
                                                                                                          via private vehicle / Walk-in, this
                                                                                                          percentage dramatically increased to 46%
                                                        1                                                 in 2007/2008.
                                                                                      0    0

                         EMS                  Private Vehicle/Walk-in                 Unknown


                                            2006/2007              2007/2008




Discharge Outcomes – 2007/2008
                        23




                   15                                                                                     The majority of trauma patients were
                                                                                                          discharged “home”. The other/unknown
                                                                                                          category represents patients discharged to
                                                                                                          locations other than previously defined or
                                                                5
                                                            3
                                                                                  4
                                                                                                3
                                                                                                          for which no specific discharge location was
                                        1
                                             2
                                                                          1
                                                                                           2              documented in the chart.

                   Home               Acute Care            Died      Nursing Home Other / Unknown


                                        2006/2007                      2007/2008




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Transfer to FMC Trauma Centre – 2006/2007

                                                 40           41


                                34


               28
                                                                                Patients who were seen at PLC ER and are
                                                                                transferred to FMC Trauma Centre with an
                                         26


                                                                                ISS ≥ 12.

                                                                                Note: Two patients for 2007/2008 were
                                                                                admitted to PLC prior to being transferred at
                                                                                FMC.
   2003/2004        2004/2005        2005/2006    2006/2007        2007/2008




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                                              PETER LOUGHEED HOSPITAL
                                              PERFORMANCE INDICATORS

                                                    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
                                                                             100.0                  100.0
scene?
Mechanical airway includes intubation (nasal and oral),
cricothyroidotomy and tracheostomy. Laryngeal mask airway
(LMAs) are considered a very effective airway however, not a               2006/2007            2007/2008
mechanical/definitive airway.
                                                                                       %Yes   %No
n = all patients with first recorded scene GCS ≤8.
       Indicator                     Yes                   No

2006/2007, n = 1               0                    1
2007/2008, n = 2               2                    0



                                                        IN-HOSPITAL CARE

Chart Documentation
Was 1 hour chart documentation present for patient
beginning with ER, including time in radiology, up to                                               24.2
admission to the OR, ICU, ward, death or transfer to
another hospital?                                                            100.0
                                                                                                    75.8



n = all patients seen in ED.                                               2006/2007            2007/2008
Indicator                      Yes                  No
                                                                                       %Yes   %No
2006/2007, n = 22              22                   0
2007/2008, n = 33              25                   8



Neurological Documentation
Was sequential neurological documentation present
on ER record if patient had a diagnosis of skull
fracture, intracranial injury or spinal cord injury?                         57.1
                                                                                                    100.0

                                                                             42.9
n = all patients seen in ED with skull fracture, intracranial injury or
spinal cord injury.
                                                                           2006/2007            2007/2008
Indicator                      Yes                  No

2006/2007, n = 14              6                    8                                  %Yes   %No

2007/2008, n = 10              10                   0


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Ambulance Reports
Are all prehospital ambulance reports from all
phases of patient transport present on the medical
record?
                                                                         100.0                   100.0


n = all patients with prehospital care provider(s)
Indicator                    Yes                     No                2006/2007             2007/2008

2006/2007, n = 21            21                      0                             %Yes    %No
2007/2008, n = 19            19                      0



ED Length of Stay (LOS)
Did the patient have a PLC ED length of stay ≤ 4
hours?
Median ED LOS: 11.03 hours          Range: 0.05 - 25.517 hours
Average ED LOS: 13.03 hours                                              95.5                    99.9

n = all patients seen in PLC ED with a known LOS.                                  4.5                     0.1
Indicator                    Yes                     No                2006/2007             2007/2008
2006/2007, n = 22            1                       21
                                                                                    %Yes   %No
2007/2008, N = 33            3                       30




Hospital Admitting Doctor
Was the patient admitted to a surgeon or an
intensivist at the PLC?
                                                                          54.5                   62.9


                                                                          45.5                   37.1
n = all patients admitted to PLC.
                                                                       2006/2007             2007/2008
Indicator                    Yes                     No
                                                                                   %Yes    %No
2006/2007, n = 22            10                      12

2007/2008, n = 35            13                      22




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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 PLC?

                                                                                             100.0
n = all patients with a known FMC ED GCS, a known time of CT
head, LOS >/= 4 hours and no head CT at sending hospital.
Indicator                  Yes                   No

2006/2007, n = 0           0                     0                  2006/2007            2007/2008

2007/2008, n = 1           1                     0                              %Yes   %No




Patient transfer
Was any patient with ISS ≥ 12 transferred to FMC
trauma centre after admission to PLC?

                                                                      95.5                   94.3


n = all patients admitted to PLC with an ISS ≥ 12.                              4.5                    5.7

Indicator                   Yes                  No                 2006/2007            2007/2008

2006/2007, n = 22           1                    21                             %Yes   %No
2007/2008, n = 35           2                    33



Missed Injuries
Did patient have any new injuries diagnosed 48
hours after arrival to the PLC?

                                                                      100.0                  100


n = all admitted patients who survive at least 48 hours

Indicator                   Yes                  No                 2006/2007            2007/2008

2006/2007, n = 19           0                    19                             %Yes   %No
2007/2008, n = 34           0                    34




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Joint Reduction
Was the joint dislocation or fracture/dislocation
reduced within 1 hour of arrival to the PLC?
Note: As of April 2007 – this indicator will also add any reduction
attempts for any joint dislocation/fracture within 1 hour of arrival to     100.0
PLC.

n = all patients with a hip, shoulder, elbow, ankle, wrist or knee
joint dislocation with a hospital LOS ≥ 1 hour and a known
reduction time.                                                           2006/2007            2007/2008
Indicator                    Yes                    No
                                                                                      %Yes   %No
2006/2007, n = 1             0                      1
2007/2008, n = 0             0                      0



Femur Fracture
Did the patient have operative management of the
femur fracture within 24 hours of arrival to PLC?

                                                                            100.0



n = all patients with operative management of femur fracture.             2006/2007            2007/2008
Indicator                    Yes                    No
                                                                                      %Yes   %No
2006/2007, n = 1             1                      0
2007/2008, n = 0             0                      0




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 at PLC?                                              100.0

Long bones include radius, ulna, humerus, tibia, femur and fibula.

n = all patients with operative management of open long bone              2006/2007            2007/2008
fracture.
Indicator                    Yes                    No                                %Yes   %No

2006/2007, n = 0             0                      0
2007/2008, n = 1             1                      0




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

                                                                              No Cases
n = all patients who have operative intervention of major facial
fracture.
Indicator                  Yes                    No

2006/2007, n = 0           0                      0
2007/2008, n = 0           0                      0



   LAPAROTOMY CATEGORIES

   These categories include all patients with suspected intra-abdominal injury requiring a
   laparotomy. Nurses and/or physicians reviewed all laparotomy cases to determine the need for
   follow-up regarding process/system issues. 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 presenting 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).


Therapeutic Laparotomies
If the patient received a laparotomy, was it
therapeutic?


                                                                              No Cases

n = all patients with Category 1 laparotomy.
Indicator                  Yes                    No

2006/2007, n = 0           0                      0

2007/2008, n = 0           0                      0




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Unplanned Return to OR
Did the patient have an unplanned return to the
operating room within 48 hours of the initial
procedure?
                                                                      100.0                  100.0


n = all patients with at least one operating room visit.
Indicator                     Yes                  No               2006/2007            2007/2008

2006/2007, n = 2              0                    2                            %Yes   %No
2007/2008, n = 5              0                    5




ICU Admission
Was there an ICU admission at the PLC?

                                                                      91.0                   85.7


                                                                                9.0                   14.3
n = all patients admitted to the PLC
                                                                    2006/2007            2007/2008
Indicator                     Yes                  No
                                                                                %Yes   %No
2006/2007, n = 22             2                    20
2007/2008, n = 35             3                    32



Unplanned ICU Admission
Was there an unplanned ICU trauma admission at
the PLC?

                                                                      100.0                  100.0


n = all patients admitted to PLC Trauma Centre.

Indicator                     Yes                  No               2006/2007            2007/2008

2006/2007, n = 22             0                    22                           %Yes   %No
2007/2008, n = 35             0                    35




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Death during First 24 Hours
Did the patient die within the first 24 hours of arrival
at the PLC?
                                                                                             80.0
All death cases are reviewed by Trauma Services. Cases may be         100.0
presented at the Adult Trauma Quality Improvement Committee if
there are system issues/concerns for follow-up.
                                                                                             20.0

                                                                    2006/2007            2007/2008
n= all patients who die.
Indicator                    Yes                No                              %Yes   %No

2006/2007, n = 3             0                  3
2007/2008, n = 5             1                  4




Mortality
Did the patient die at the PLC?


                                                                      86.4                   85.7



                                                                      13.6                   14.3
n = all patients arriving at PLC
Indicator                    Yes                 No                 2006/2007            2007/2008

2006/2007, n = 22            3                   19                             %Yes   %No

2007/2008, n = 35            5                   30




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ROCKYVIEW GENERAL HOSPITAL (RGH)

April 1, 2007 – March 31, 2008

Capturing the major trauma population at the RGH is based on a review of the monthly injury
discharges prepared by Quality Safety Health Information (QSHI). Trauma patients with an Injury
Severity Score (ISS) ≥12 were identified through chart audit.

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 (ATR) ranges between 12 and
75; the higher the ISS, the more serious the injury.

Patients that are admitted to the hospital with a trauma related mechanism of injury and any of
the following injuries prompts a chart audit:
       - head injury and or comatose/unspecified comatose;
       - rib fracture > 1 or unknown with pneumothorax/hemothorax;
       - multiple body regions injury;
       - abdominal injury;
       - spinal injury;
       - any significant mechanism of injury (cause)
       - Emergency Department deaths

Staff is encouraged to complete a trauma follow-up form in the Emergency Department with
information on the traumatically injured patient. Forms were collected on a regular basis. System
issues were referred directly to Regional Trauma Services.

The following reports reflect the major trauma population (ISS ≥12) that was identified and
reviewed by Trauma Services, based on the evaluation process list identified above.

Yearly Major Trauma Totals

                             33
        30                                          29
                  28
                                        23                        The RGH five year trend demonstrated a
                                                                  decrease from 2003/2004 to 2004/2005 (6.7%),
                                                                  an increase in 2005/2006 (17.9%), a decrease in
                                                                  2006/2007 (30.3%) and an increase in 2007/2008
                                                                  (20.7%).

                                                                  The numbers do not reflect the patients that
                                                                  arrived in ED and were transferred to Trauma
                            RGH
                                                                  Centres.
    2003/2004   2004/2005   2005/2006   2006/2007    2007/2008




ISS Scores 2007/2008

          Range: 13-29 Average: 18 Median: 17




                                                                 124
Regional Trauma Services                                                                                                                                                                                                2007/2008
PLC & RGH – Trauma Statistics & Performance/Outcome Data



Monthly Major Trauma Totals


                                                     2007/2008                                                                                                         2006/2007

                                                           5                                                                                                                  4     4




                                                                                                                               # of patients
                                                                                                         4
# of patients




                                                                                                                                                                                                      3
                                          3         3                              3
                                                                                                                                                     2           2                        2                       2
                    2                                                      2              2       2
                                                                                                                                               1                        1                       1           1
                          1         1                               1
                                                                                                                                                           0

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




Males/Female


                                            16
                                                                                         15
                                                                                                        14
                                                                                                                                         Males outnumber the females at RGH, a ratio
                                                                                                                                         of 1.07:1
                              7




                           2006/2007                                                    2007/2008

                                                         Males            Females




Age Distribution


                                                                                                                     9




                                                                                                                         4


                                                                                                                                        In 2007/2008, the majority of the population
                                                                               5                  5              5                      was between 55 and >84.
                                                                                              4              4

                                                3               3

                      2

                1                    1               1              1               1

                                0

                18-24           25-34           35-44          45-54           55-64          65-74          75-84   > 84



                                                    2007/2008                    2006/2007




                                                                                                                             125
                     Regional Trauma Services                                                                                                                      2007/2008
                     PLC & RGH – Trauma Statistics & Performance/Outcome Data




                     Mechanism of Injury (MOI)


                                                               20
                                                                      18                                                       The MOI is reported by four broad
                     # of patients




                                                                                                                               categories: transportation, falls, violence
                                                                                                                               and other. These are in keeping with the
                                                                                                                               focus of the Calgary Health Region’s injury
                                                                                        6
                                                                                                                               control initiatives. Other includes animal
                                        3       3
                                                                                                 1
                                                                                                            0
                                                                                                                    1          related incidents (for example riding). Falls
                                                                                                                               continue to be the number one mechanism
                                     Transportation                Falls               Violence                 Other          of injury at the RGH.

                                                                   2007/2008          2006/2007


                     Mode of Arrival


                                                21
                                                            20


                                                                                                                              The majority of patients were transported
                                                                                                                              by EMS to the RGH this year; consistent
                                                                                             8                                with 2006/2007.

                                                                                                     3



                                                      EMS                             Private Vehicle/Walk-in


                                                            2007/2008              2006/2007




                     Discharge Locations




                16
                                                                                                                          The majority of trauma patients in both 2007/2008 and
                     13
# of Patients




                                                                                                                          2006/2007 were discharged “home”. The other/unknown
                                                                                                                          category represents patients discharged to locations other
                                                                                                                          than previously defined or for which no specific discharge
                                                                                                                          location was documented in the chart.
                                                        5 5
                                            4
                                                2                          2                     2
                                                                                            1            1 1
                                                                               0

                Home                    Acute Care          Died       Nursing Home         Rehab     Other/Unk




                                                                                                                        126
   Regional Trauma Services                                                                                 2007/2008
   PLC & RGH – Trauma Statistics & Performance/Outcome Data



                                         ROCKYVIEW GENERAL HOSPITAL
                                           PERFORMANCE INDICATORS

                                                 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),                    100.0                    100.0
cricothyroidotomy, tracheostomy and laryngeal mask airway
(LMAs).

n = all patients with first recorded scene GCS ≤ 8.                      2006/2007                2007/2008
      Indicator                    Yes                  No
                                                                                     %Yes   %No
2006/2007, n=2               2                   0
2007/2008, n=1               1                   0



                                                      IN HOSPITAL CARE

Chart Documentation
Was 1 hour chart documentation present for patient
beginning with ER, including time in radiology, up to
admission to the OR, ICU, ward, death or transfer to                       57.1                     53.6
another hospital?

n = all patients seen in the ED                                            42.9                     46.4


Indicator                    Yes                 No                      2006/2007                2007/2008

2006/2007, n=21              9                   12                                  %Yes   %No

2007/2008, n=28              13                  15




                                                              127
   Regional Trauma Services                                                                                2007/2008
   PLC & RGH – Trauma Statistics & Performance/Outcome Data




Neurological Documentation
Was sequential neurological documentation present
on ER record if patient had a diagnosis of skull
fracture, intracranial injury or spinal cord injury?                                                 15
                                                                       100

n = all patients seen in the ED with skull fracture, intracranial                                    85
injury or spinal cord injury
Indicator                    Yes                     No
                                                                    2006/2007                     2007/2008
2006/2007, n = 14            14                      0
                                                                                      Yes   No
2007/2008, n = 20            17                      3




Ambulance Reports
Are all prehospital ambulance reports from all
                                                                                                     4.8
phases of patient transport present on the medical
record?                                                               20.0


                                                                                                    92.2
                                                                       80.0

n = all patients with prehospital care provider(s)
Indicator                    Yes                     No
                                                                    2006/2007                     2007/2008
2006/2007, n = 20            16                      4
                                                                                 %Yes       %No
2007/2008, n = 21            20                      1




Missed Injuries
Did the patient have any new injuries diagnosed 48
hours after arrival to the RGH?


                                                                      90.9                        92.3

n = all admitted patients who survive at least 48 hours
                                                                                9.1                        7.7
Indicator                    Yes                     No
                                                                    2006/2007                 2007/2008
2006/2007, n = 22            2                       20
                                                                                %Yes        %No
2007/2008, n = 26            2                       24




                                                              128
   Regional Trauma Services                                                                            2007/2008
   PLC & RGH – Trauma Statistics & Performance/Outcome Data



Therapeutic Laparotomy
If the patient received a laparotomy, was it
therapeutic?



n = all patients with Category 1 laparotomy.

Indicator                    Yes                  No                              No Cases
2006/2007, n = 0             0                    0

2007/2008, n = 0             0                    0



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


                                                                        100.0



n = all patients with femur fracture, stable enough for operative
care within 24 hours or who survive at least 24 hours                 2006/2007                2007/2008
Indicator                    Yes                  No
                                                                                  %Yes   %No
2006/2007, n = 1             0                    1

2007/2008, n = 0             0                    0



Long Bone 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 at
RGH?
(The long bones include the radius, ulna, humerus,
tibia, fibula, femur)
                                                                                  No Cases
n = all patients with open long bone fracture, stable enough for
operative repair in desired time frame or who survived 6 hours
(Grade III) / 12 hours (Grade I or II)
Indicator                    Yes                  No

2006/2007, n = 0             0                    0

2007/2008, n = 0             0                    0




                                                                129
   Regional Trauma Services                                                                               2007/2008
   PLC & RGH – Trauma Statistics & Performance/Outcome Data



Unplanned OR
Was there an unplanned return to OR within 48
hours of initial procedure?


                                                                           100.0
n = all patients with at least one OR

Indicator                      Yes                  No
                                                                         2006/2007                2007/2008
2006/2007, n = 3               0                    3
                                                                                     %Yes   %No
2007/2008, n = 0               0                    0




ORIF of Major Facial Fractures
If the patient had an ORIF of facial fractures (major
mandible, maxilla, or orbit) was it completed ≤ 7
days of injury?

                                                                                     No Cases
n = all patients with operative repair of major facial fractures
Indicator                      Yes                  No

2006/2007, n = 0               0                    0

2007/2008, n = 0               0                    0




Joint Dislocation
If the patient had joint dislocation (hip, shoulder,
elbow), was there an attempt to reduce it within one
hour of arrival to the RGH?

                                                                                     No Cases
n = all patients with joint dislocation
Indicator                      Yes                  No

2006/2007, n = 0               0                    0

2007/2008, n = 0               0                    0




                                                                   130
   Regional Trauma Services                                                                             2007/2008
   PLC & RGH – Trauma Statistics & Performance/Outcome Data



Patient Transferred
Was the ISS ≥12 patient transferred from the RGH
to the FMC Trauma Centre?


                                                                      90.5                       86.2



                                                                                9.5              13.8
n = all patients admitted to RGH with an ISS ≥ 12
Indicator                   Yes                  No                 2006/2007                  2007/2008

2006/2007, n = 21           2                    19                              %Yes   %No

2007/2008, n = 29           4                    25



Hospital Admission
Was the patient admitted to a surgeon or an
intensivist at the RGH?

                                                                      60.9
                                                                                                92.6

                                                                      39.1
                                                                                                          7.4
n = all patients admitted to the RGH
                                                                    2006/2007                 2007/2008
Indicator                   Yes                  No

2006/2007, n = 23           9                    14                             %Yes    %No


2007/2008, n = 27           2                    25



ICU Admission
Was there an ICU admission at the RGH?



                                                                      78.3
                                                                                                96.6


n = all patients admitted to the RGH                                  21.7                                3.4
Indicator                   Yes                  No
                                                                    2006/2007                 2007/2008
2006/2007, n = 23           5                    18
                                                                                %Yes    %No
2007/2008, n = 29           1                    28




                                                              131
   Regional Trauma Services                                                                            2007/2008
   PLC & RGH – Trauma Statistics & Performance/Outcome Data



Unplanned ICU Admission
Was there an unplanned ICU admission at the
RGH?


                                                                      95.7


                                                                                4.3
n = all patients admitted to the RGH
                                                                    2006/2007                2007/2008
Indicator                   Yes                  No

2006/2007, n = 23           1                    22                             %Yes   %No


2007/2008, n = 29           0                    0



CT
If the patient had a GCS<13 (first recorded GCS at
the RGH), was the CT performed within 4 hours of
arrival to the RGH?
                                                                      100.0
                                                                                               100.0




                                                                    2006/2007                2007/2008
n = all patients with a known RGH ED GCS<13 and a known time
of CT head
Indicator                   Yes                  No                             %Yes   %No

2006/2007, n = 2            2                    0

2007/2008, n = 2            2                    0



Length of Stay
Did the patient have a RGH ED length of stay ≤ 4
hours?

Median: 16.09 hrs
Average: 16 hrs                                                       94.7                     96.3
Range: 0.05 – 23.10 hrs
                                                                                5.3                      3.7
n = all patients seen in RGH ED with a known ED LOS. Direct
admissions are excluded                                             2006/2007                2007/2008
Indicator                   Yes                  No
                                                                                %Yes   %No
2006/2007, n = 19           1                    18

2007/2008, n = 27           1                    26




                                                              132
   Regional Trauma Services                                                                           2007/2008
   PLC & RGH – Trauma Statistics & Performance/Outcome Data




Mortality
Did the patient die at the RGH?

                                                                      78.3                     82.8


                                                                      21.7                     17.2

n = all patients arriving at the RGH                                2006/2007                2007/2008
Indicator                    Yes                 No
                                                                                %Yes   %No
2006/2007, n = 23            5                   18

2007/2008, n = 29            5                   24




Mortality within 24 hours
Did the patient die within the first 24 hours of arrival
at the RGH?

                                                                                               60.0
                                                                      100.0

                                                                                               40.0

n = all patients who died at RGH
                                                                    2006/2007                2007/2008
Indicator                    Yes                 No

2006/2007, n = 5             0                   5                              %Yes   %No


2007/2008, n = 5             2                   3




                                                              133
      The Imperative for Injury
            Prevention




Prepared by:
Nancy Staniland, Manager
Sherry Elnitsky, Research Project Coordinator
December, 2008
Injury Prevention and Control Services
Healthy Living, Public Health Portfolio
http://www.calgaryhealthregion.ca/injuryprevention
                                The Imperative for Injury Prevention
    Injuries are a major public health problem that contribute significantly to death, hospitalization,
    emergency department visits and lost quality of life in Alberta Health Services - Calgary Health
    Region. Every day at least one resident dies from an injury, every hour a resident is hospitalized
    for an injury and every five minutes a resident visits an emergency department for treatment of
    an injury. The annual health care cost of these injuries is a staggering 115 million dollars.
    Weighing this picture against the fact that a huge majority of all injuries are predictable and
    therefore preventable, the imperative for a stronger effort to prevent and reduce injuries is clear.

    An overview of the injury data in the Profile of Injuries in Alberta Health Services - Calgary
    Health Region 2007-08 (the Profile) is discussed within the context of best practice evidence,
    current injury prevention activities and the potential for enhanced prevention efforts. The Profile
    summarizes injuries in the adult and pediatric populations of the Region. The Profile
    summarizes all injuries in the Region that are treated in regional emergency departments,
    urgent care centers and acute care facilities as well as injury-related deaths.

    Assessing the continuum of injuries from mild to severe is important because of the implications
    for the provision and utilization of health care resources. Management of the most severe
    injuries requires a complex range of services provided through the Region’s tertiary trauma
    system. Management of less severe injuries requires fewer resources per individual injury but a
    significant allocation of resources to handle the volume of cases and the sheer magnitude of the
    injury problem. The graphic representation below of an iceberg demonstrates the full scope of
    injuries across the population in the region for 2007-08. For each injury death, there were 17
    injury-related hospitalizations, 238 injury-related emergency department visits and an untold
    number of injuries treated in outpatient locations, by family physicians or at home.



               1


              17                         Since prevention requires targeted efforts, the causes of
:
                                         injury known to contribute extensively to the overall burden
          238
                                         of injury are highlighted. These include unintentional injuries
    Unknown
    Number:
                                         (falls, transportation) and intentional injuries (violence and
                                         suicide). The overall patterns apparent in the data have
                                         been relatively consistent over the past six years, although
                                         there have been some statistically significant changes
                                         between the years 2002-03 and 2007-08 that are
                                         highlighted in each section.




                                                    136
Unintentional Injuries

Falls
Falls continue to be the leading cause of injury across all age groups. Fall-related emergency
department visits were highest for the youngest and oldest segments of the population. Males
were at greater risk in the younger age groups while females were more at risk for a fall-related
emergency department visit in the older age groups. Fall-related injuries accounted for 77% of
all injury-related hospitalizations for residents 65 years of age and older. A third of these fall-
related injuries were a hip fracture which is a very serious and life altering event for an older
adult. Both the hospitalization rate and the emergency department visit rate related to fall
injuries is significantly lower in 2007-08 compared to 2002-03.

Falls result from a complex interaction of individual behavior in the context of the physical
environment. Young children are particularly at risk due to their developmental level and the
risks of their home and community environments, including the level and appropriateness of the
supervision provided by their caregivers. Youth and adults are exposed to fall risks in sport and
recreational activities as well as in employment conditions and circumstances. Older adults face
a complex array of intrinsic and extrinsic factors which contribute to an increased risk of falls. As
the relative proportion of individuals over 65 years of age increases, the burden of fall-related
injuries and requirements for health care services will increase.

Prevention of falls and fall-related injuries is not simple or straightforward but requires a range of
actions across a variety of levels, from public policy through individual behavior change. For
example, buildings that require window guards to prevent young children from falling out of open
windows or from dislodging window screens are important and have been shown to be
effective.1 Playgrounds that require resilient surfacing and a reduction in the overall height of the
play structures also contribute to a reduction in fall injuries for children.2 Fall risks in the home
are also significant and parents and caregivers require education and support to make the
necessary modifications to keep young children safe through the use of stair gates and other
safety equipment. Supervision of young children is an important fall prevention strategy and
studies have indicated that many parents have unrealistic expectations about the appropriate
level of supervision required.3

Falls and fall-related injury prevention in older adults is an area that has been studied
extensively due to the magnitude and severity of the problem. Research has demonstrated that
an assessment of an individual’s fall risk, fall history and review of modifiable and non-
modifiable fall risk factors followed by a combination of interventions in an individualized care
plan is effective.4 A very effective fall prevention strategy for independent, community dwelling
older adults is the provision of exercise opportunities to maintain core strength and balance.5
Hip protectors are an important injury prevention strategy, especially for high risk,
institutionalized older adults. Despite the benefit for older adults in other settings, hip protectors
are not widely used.6

Alberta Health Services – Calgary Health Region made a major commitment to fall and fall-
related injury prevention in older adults with the establishment of the Regional Falls Project in
2005. The project designed and implemented a series of pilot projects across the continuum of
care for older adults which have now been operationalized. In acute care, fall risk assessment
and individualized care plans have been developed. In Home Care, a falls team has been
established to provide specialized assessment and follow up for older adults who have
experienced a fall or are at high risk of falling. In the community, core strength and balance


                                                  137
exercise programs are being delivered in partnership with the City of Calgary to isolated, low
income seniors. The Regional Falls Project has had limited capacity to undertake interventions
in emergency departments or to support interventions in long term care settings. Additional
funding for the project is required to expand the existing strategies and to initiate best practices
that have not been implemented to date.

Transportation
Transportation-related injuries are a significant problem, especially for residents between the
ages of 15 and 44 years. Males in this age range were at least twice as likely as females to be
hospitalized for transportation-related injuries. Transportation-related events were the second
leading cause of injury overall. Utilization of emergency departments for transportation-related
injuries is significantly higher in 2007-08 compared to 2002-03.

While a variety of transportation-related events (motor vehicle, cycling, pedestrian) contribute to
the overall mortality and morbidity, the bulk of the transportation-related injury burden was due
to motor vehicle-related events. Overall, the risk of a transportation injury requiring an
emergency department visit or a hospitalization is highest for motor vehicles, followed by cycling
and walking.

 A different pattern of risk is observed for school aged children 6 to 12 years old. Within this age
group, risk for a transportation injury requiring either an emergency department visit or a
hospitalization is highest for cycling followed by motor vehicles and walking.

Safe operation of a motor vehicle is a complex activity where driver behaviors interact with the
physical, social and political environments that influence traffic safety. Increasing road users
and intensity of economic activity, combined with social and technological influences in the
driving environment, such as cell phones, contribute to the complexity and risk.

There are a number of actions to reduce motor vehicle collisions which, when applied in
combination, have demonstrated a reduction in injuries and deaths. Key strategies are required
at both the policy and environmental level that will subsequently set the context for changes in
individual driver behavior. Leading international examples, achieved through a combination of
aggressive pubic policies, strengthened enforcement efforts, engineering and road design
modifications and intensive public education7 have documented a significant reduction in
collisions, deaths and injuries.

Policy actions which support safe transportation are a key injury prevention strategy.
Significant progress has been made towards strengthened Graduated Driver Licensing (GDL) in
Alberta with modifications to the existing regulations anticipated to be approved by the
Transportation Minister this year for implementation in 2009-2010. If approved, the changes will
include night time driving restrictions, passenger restrictions involving peers plus additional
requirements around learner placards and lower demerit thresholds for probationary drivers.
Alberta Health Services – Calgary Health Region, worked actively with other stakeholders in the
Region and across the province to build support for the strengthened GDL regulations through
the development of a Regional position paper on strengthened GDL and communication
strategies through various channels.

Other opportunities exist to strengthen legislation around occupant restraints by adding demerits
to seatbelt violations and by passing booster seat legislation. Both of these policy approaches
have been shown to be effective in reducing injuries and deaths related to motor vehicle
collisions.8,9 The level of sustained action on policy priorities amongst the traffic safety partners


                                                 138
in Alberta has unfortunately not been adequate to make progress on these two key policy
directions. Alberta Health Services – Calgary Health Region continues to work with diverse
traffic safety partners in the Alberta Occupant Restraint Program (AORP) to plan and implement
broad educational, enforcement and public awareness strategies in support of occupant
restraints and to continue to build the base of support required for policy level change.

The Region is also working with local and provincial partners to implement the Alberta Traffic
Safety Plan originally developed in 2006. An Alberta Traffic Safety Plan Calendar has been
developed in 2008 which highlights key traffic safety issues to be focused on each specific
month of the year. The purpose of the calendar is to facilitate coordination of communication,
enforcement and community based activities around the key traffic issue such as impaired
driving, speed, and intersection safety. Alberta Health Services – Calgary Health Region has
renewed a strong partnership with the Calgary Police Service and facilitated joint meetings to
explore collaborative work on traffic safety between the two organizations. Key areas of focus
will be on impaired driving, occupant restraints, intersection safety and supports to community
based educational opportunities. Joint messaging and media work are planned to reinforce the
fact that the majority of motor vehicle collisions are preventable. Actions that reduce the
number of collisions and the resulting injuries will not only impact enforcement resources but will
also directly contribute to an improvement in health system capacity.


Intentional Injuries

Violence
Interpersonal violence is a significant injury cause in the Profile. Violence is the third leading
mechanism of injury resulting in an emergency department visit or hospitalization due to injury
and the fourth leading reason for hospitalization due to injury. Violence-related injuries were
highest for residents between the ages of 15 and 44. Compared to females between 15 and 44
years of age, males were six to eleven times more likely to be hospitalized for a violence-related
injury and three to four times more likely to be seen in the emergency department for an injury
resulting from violence. There is a significant increase in these injuries treated at emergency
departments between 2002-03 and 2007-08.

Calgary is a major urban centre with a rapidly expanding population and there is increasing
evidence of the social issues and pressures that accompany large cities. An increase in
interpersonal violence is not necessarily surprising or unexpected. The earlier economic surge
of the Calgary and area economy has been beneficial to many, but also tends to widen the gap
between the most and the least affluent members of the population. The cost of some of the
basic necessities of living, such as housing and food, make them unattainable for those living at
the lowest economic level. Indicators such as the level of homelessness, poverty, use of
shelters and food banks are all showing an upward trend.13 Another impact of the size of the city
and the level of economic activity is the attraction to known criminal elements that rely on the
availability of disposable income to support illegal activities, such as the trafficking and sale of
street drugs. Youth experience many influences through the media and popular culture and this
may be contributing to the ‘normalization’ of interpersonal violence. Increasing gang related
violence, including murders of innocent bystanders, is an alarming reality in Calgary.

Action across all sectors is needed to address the prevention of violence, including such areas
as justice, policing, social services, infrastructure, education and health. There are many
promising initiatives currently being undertaken such as the Calgary Police Service’s Gang Life
Prevention Campaign, school based initiatives aimed at identifying and eliminating bullying and


                                                139
urban planning initiatives that work to create safer environments through proactive urban
design. The potential to prevent interpersonal violence, especially amongst youth and young
adults, may be further strengthened through public policy initiatives which address the
availability and consumption of alcohol through such measures as increasing the legal drinking
age, controlling hours of operation of bars, nightclubs and liquor stores and the establishment of
minimum drink prices.14 Evidence for the effectiveness of these measures has not been firmly
established but definitely warrant further research and review.

Suicide
In 2007-08, suicide was the second leading cause of injury-related death for residents up to age
44 and the leading cause of injury-related death for residents 45 years and over. Males were
twice as likely as females to die by suicide. But suicide attempts that required emergency
department visits or hospitalizations were higher among females, unlike the gender pattern seen
in the other major causes of injury. There is a significant decrease in hospital utilization for
suicide-related injuries between 2002-03 and 2007-08.

Suicide is a complex issue and a wide variety of factors such as substance abuse, addiction,
mental health issues, sexual orientation, culture and family history can all contribute to the risk
for suicide in any given individual. The Alberta Suicide Prevention Strategy was developed in
2005 to provide the framework for coordinated action across multiple sectors and with many
diverse stakeholders. The strategy identifies eight broad goals which reflect the best evidence
for development of a comprehensive system to prevent and limit the impact of suicide across
the province. Key goal areas include activities to enhance mental health, improved intervention
and treatment for those at risk of suicide or affected by suicide, increasing effort to reduce
access to lethal means of suicide and increased research and surveillance.15

The Region has undertaken a number of key initiatives which align with the provincial suicide
prevention strategy, including a major focus on suicide postvention and support for survivors.
Research indicates that those who have lost a loved one through suicide are at risk for
complicated grieving and are themselves at higher risk for suicide.16 Postvention protocols for
follow up with survivors are in place within the Mental Health Program areas. A number of
resources have been developed such as Hope and Healing: A Practical Guide for Survivors of
Suicide which has also been redeveloped into an aboriginal version entitled Healing Your Spirit:
Surviving After the Suicide of a Loved One. Processes and connections with key community
partners such as bereavement support groups and the medical examiner’s office have been
established to facilitate distribution of the postvention support materials. Another current focus is
on men at risk for suicide, based on the evidence that men complete suicide at a much higher
rate than women and also that they do not readily seek help for mental or emotional health
issues through the typical channels.17

Other opportunities exist to create a more supportive environment for suicide prevention and
intervention, including enhanced screening for suicide risk across all care settings of the
Region. Availability and accessibility of mental health services, treatment for addictions,
affordable counseling and follow up of individuals at risk is a persistent challenge and strategies
to increase the system capacity must be found.

Conclusion and Recommendations
The development and release of the Alberta Injury Control Strategy18 was the culmination of
many months of consultation with a broad range of stakeholders across many sectors. It
consolidated the evidence on prevention and control of injuries and provided wide sweeping



                                                 140
recommendations for coordinated provincial action on injuries. Since the document was
released in June 2003, several attempts have been made to have the strategy formally
endorsed at the provincial government level. To date, this endorsement has still not been
achieved. The document outlines seven strategic goals with corresponding objectives and
recommended actions. There are also key responsibilities for the various sectors outlined,
including specific responsibilities for health regions. Alberta Health Services – Calgary Health
Region has made a significant and sustained commitment to injury prevention and control over
many years and is fulfilling many of the responsibilities outlined in the strategy, including
programs and services to prevent, treat and rehabilitate injuries. There are, however, some
responsibilities that have not yet been undertaken in a significant way.

The cost of preventing injuries is small compared to the staggering cost of treating and
rehabilitating them but preventing injuries cannot be achieved without adequate resource
allocation. With the increasing demand for emergency and acute care services and the
escalating costs associated with these areas, Alberta Health Services – Calgary Health Region
has an opportunity to review if the existing investments to prevent and limit injuries are
adequate for the size and impact of the problem. Based on the Alberta Injury Control Strategy,
some distinct areas of responsibility that could reduce the demand on services are as follows:
1. Establish an agenda for advocacy on key public policies that would strengthen injury
   prevention efforts and link these to appropriate municipal, provincial and federal levels of
   government.
2. Evaluate opportunities to engage in new partnerships and new funding approaches which
   focus resources on limiting the circumstances that create injury (e.g., joint strategies to
   reduce impaired driving in collaboration with enforcement groups).
3. Allocate additional financial and human resources to provide effective injury prevention
   programs in collaboration with other community based injury prevention stakeholders. (e.g.,
   expand the provision of fall prevention exercise programs at the community level for older
   adults).
4. Evaluate opportunities to integrate primary and secondary injury prevention information and
   resources into all clinical practice areas and interactions, including injury risk screening and
   appropriate referral. Formalization of an injury prevention program presence at the Alberta
   Children’s Hospital would be an important first step.
5. Educate and train the staff to integrate injury prevention strategies into their workplaces,
   methods of working and personal lives.
6. Engage evaluation and research resources to monitor progress on injury prevention priorities
   including the establishment of stronger relationships with academic partners.




                                                141
                                         References
1
     Pressley, J and Barlow, B. (2005). Child and adolescent injury as a result of falls from
       buildings and structures. Injury Prevention: 11 (5), 267-73.
2
     Laforest, S., Robitaille, Y., Lesage, D., Dorval, D. (2001). Surface characteristics,
       equipment height, and the occurrence and severity of playground injuries. Injury
       Prevention: 7 (1), 35-40.
3
     Morrongiello, Barbara (January 2008). Child Injuries are Not “Accidents”: Parent and
       Child Factors Affect Risk of Unintentional Injury. Teleconference presentation on
       unpublished research findings as part of the ACICR teleconference series, January 8,
       2008.
4
     Campbell, A.J. & Robertson, M.C. (2007). Rethinking individual and community fall
       prevention strategies: A meta-regression comparing single and multifactorial
       interventions. Age and Ageing: 36, 656-662.
5
     Ibid.
6
     Holzer, G. & Holzer, L.A. (2007). Hip protectors and prevention of hip fractures in older
       persons. Geriatrics: 62 (18), 15-20.
7
     Alberta Government (October 2006). Alberta Traffic Safety Plan: Saving Lives on
        Alberta’s Roads.
8
     Alberta Occupant Restraint Program (AORP). (December 2005). The Introduction of
        Demerit Points to Increase Compliance with Seat Belt and Child Safety Seat
        Legislation in Alberta.
9
     Weber, K. (2000). Crash protection for child passengers: A review of best practice.
       UMTRI Research Review: 31(3).
10
     Alberta Infrastructure & Transportation. (2007). Collision Statistics, 2000 through 2006.
        Retrieved February 1, 2008 from http://www.acicr.ualberta.ca.
11
     Alberta Centre for Injury Control and Research. (2007): Comparison of Alberta’s GDL
        Program with Recommended Best Practices. Retrieved February 1, 2008 from
        http://www.acicr.ualberta.ca
12
     Alberta Centre for Injury Control and Research (2007). Call to Action: Improve Alberta’s
        GDL Program. Retrieved February 1, 2008 from http://www.acicr.ualberta.ca.
13
     Vibrant Communities Calgary (2008). Winter 2008 Newsletter. Volume 4, Issue 1.
14
     Vingilis E. (2007). Limits on Hours of Sales and Service: Effects on Traffic Safety.
        Transportation Research Circular: E-C123, 120-129.
15
     Alberta Mental Health Board. (2005). A Call to Action: The Alberta Suicide Prevention
        Strategy.
16
     Ibid
.
17
     Centre for Suicide Prevention. (2007). Men and Suicide, Part 1: Risk Factors. SIEC Alert
       #65, April.
18
     Alberta Centre for Injury Control and Research. (2003). Alberta Injury Control Strategy.




                                              142
            Shock Trauma Air Rescue Society (STARS) Trauma Report 2008


The Alberta Shock Trauma Air Rescue Society (STARS) provides critical care level rotary
wing transport for trauma patients throughout Alberta as well as both north and south
eastern BC. Two pilots, a paramedic and a nurse are ready 24 hours a day, seven days a
week at three bases to provide care and transport to critically ill and injured patients. A
Referral Emergency Physician accompanies patients on the helicopter on about 15% 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 an individual, to being called by a partner in the “Chain of Survival” for
assistance with an emergency. In all cases, the ELCs 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
co-ordination of medical advice and transportation as required (regardless of whether rotary
resources are used for any particular mission). 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 ELC, has an excellent working and logistical arrangement with SARCC (a
Calgary Health Region referral, transport, and bed utilization communication service).
SARCC helps to make sure patients and consultants are linked together in a fashion that
maximizes utilization of available operating room, bed, and critical care resources. This
information is now immediately available to assist STARS’ Referral Emergency Physicians
in making sure patients are transported to the facility best able to look after them. This
system is extremely effective.

The STARS Quality Management Program (medical component) includes rigorous 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, pediatric 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.

STARS has a very active outreach and education program and 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 Advanced Medical Care (AMC) critical thinking skills. 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. Our mobile program also allows us to deliver advanced medical
care training to rural health providers that use our services. It is an excellent means of
ensuring our teams work towards the common goal of superb patient care.

STARS transports trauma patients based on standards and utilization guidelines arrived
upon by local consensus and research. 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. One primary response aircraft is based in Calgary, Edmonton, and Grande Prairie
with two back up helicopters available for maintenance periods.



                                           143
We have just recently welcomed the addition of a brand new AW 139 helicopter to our fleet,
which will be operational in mid to late 2009. This aircraft has increased capabilities on
multiple fronts including speed, range, enhanced poor weather capabilities, as well as a
custom designed medical interior. We are still working on the logistics as to where it will
best be deployed amongst our 3 bases.




The following figures provide a breakdown of our trauma related activities over the past
year.


Figure 1 – Trauma related transports over the last 12 months in adult patients:
Figure 2 - Trauma related transports over the last 12 months in pediatric patients:




                                         145
   Figure 3 – Trends in Adult Trauma (≥17 yrs of age) transported by STARS into the CHR
   over 3 years:




Figure 4 – Trends in Pediatric Trauma (≤17 years of age) transported by STARS into the
CHR over 3 yrs:
As is evident in the graphical representations, traffic accidents, wilderness and recreation
activities, as well falls continue to be the most significant mechanisms of trauma in our
society. Continued education of the public in the prevention of injuries of this nature is
warranted.



Prepared by:




Michael J. Betzner MD FRCPc
Senior Medical Director STARS
Emergency Physician, CHR




                                            147
Calgary
Firefighters Burn
Treatment Centre
Report
Project Leads:
   • Ms. Michelle Mercado, Data Analyst
      Regional Trauma Services


  •   Ms. Lucy Weir, Patient Care Manager
      PCU 31/32 (Burn Unit)
     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 Calgary Firefighters Burn Treatment Centre opened in 1987, and renovated in November
     2003. The unit is 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, social workers, and a psychiatric team, 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, hypothermia or frostbite, comparing April 1, 2007 to March 31, 2008 with
     previous fiscal years.




                            Admissions                                               Hospital Days (Total)

                      93                                                             2216
      83                                                 80                                                              1904
                                            72                                                               1588
                                65                                       1536                    1444
      73
                      69
                                           55            58
                                47
                       24

        10                                 17            22
                               18                                       2003/2004   2004/2005   2005/2006   2006/2007   2007/2008

   2003/2004    2004/2005    2005/2006   2006/2007   2007/2008

               Male           Female             Total




        2007/2008 male to female ratio: 2.6:1                          2007/2008 Median length of stay (LOS): 11.5
There has been a 10% increase in admissions since                          Average LOS: 23.8            Range: 1 - 225
                   2006/2007.




                                                                 151
                                                             Month of Admission
                                                                 2007/2008

                                                                                 10
                                 9                                   9                                                    9
                  8
                                                       7                                                    7
                                            6
                                                                                               5                                         5         5




       0

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




                                              Month of Admission by Fiscal Year
                      Apr         May        June       July          Aug          Sept            Oct           Nov            Dec          Jan         Feb     Mar
2007/2008              0               8          9          6             7           9             10              5           7            9           5          5
2006/2007              6               3          8          3             13          5              8              3           8            8           4          3
2005/2006              8               3          5          7             4           2              3              10          8            8           4          3
2004/2005              10              7          5          15            8           10             2              11          6            9           7          4


                                                             Age Distribution



                                                                     20

                            14                    13
        12
                                                                                           8                     8
                                                                                                                                     3                    2


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

                                                                               2007/2008

2007/2008 median: 42, average age: 41.5                                                                  2006/2007 median age: 44, average age: 43


                                                  Age Distribution by Fiscal Year
                       </= 20              21-30             31-40               41-50               51-60               61-70               71-80              >81
2007/2008               12                  14                13                  20                  8                    8                  3                  2
2006/2007                  6                10                16                  20                  11                   5                  2                  2
2005/2006               14                  13                   9                15                  8                    5                  0                  1
2004/2005                  7                24                10                  24                  12                   5                  6                  5
2003/2004                  9                17                17                  26                  8                    3                  1                  2




                                                                           152
The age distribution shows the characteristic peak in young adults sustained into mature
adulthood and also involves a growing number of senior citizens, groups of the population whose
vulnerabilities differ, but nevertheless render them susceptible to thermal injury.


                                                        Place of Occurrence


                     40
                                    35                                         33                                         33
                                         29 29                                                    30
           27                                                                                                                  26
                                                                                                                27
                                                                  20                                                                21
                16                                                                                         15
                                                                          12



           2003/2004                2004/2005                     2005/2006                       2006/2007               2007/2008


                                                  Home      Worksite            Other / Unknown


  32.5% (26/80) sustained injuries in work related incidents 2007/2008
  20.8% (15/72) sustained injuries in work related incidents 2006/2007


An increase in the number of burn cases may be linked to inadequate training and manpower
demands in the workplace. 18.5% of incidents resulting in injury occurred in the workplace in
2005/2006 and 20.8% in 2006/2007. In 2007/2008, 32.5% of injuries occurred in the workplace.


                                                   Mechanism of Burn Injury




                              56                                                                                          59
  52                                                         55
                                                                                             51



                    17                   14        15                                                            14                      17
                                                                           0 9                                                                7
       5        5         3         4         4                                                             6                   5
                                                                      0             1                  0              1             2

       2003/2004                   2004/2005                      2005/2006                       2006/2007                    2007/2008



       Flame/Contact with Hot Object      Chemical       Electrical       Frostbite/hypothermia    Other (e.g. smoke inhalation) / Unknown




                                                                          153
                ICU Admissions                                                          Operative Intervention

                                                                                                            157                     167
                                                                                                                         151


    62                                              65                                        97
                                                                                85
                  55             53
                                                                          42             44            36           44
                                                                                                                               31
         26                           19
                       10
                                                         15
                                                                       2003/2004 2004/2005 2005/2006 2006/2007 2007/2008

 2004/2005    2005/2006       2006/2007       2007/2008
                                                                                                 Patients     Procedures
          No ICU Admission             ICU Admission




                                                          Mortality Rate


                                                                                                            8.8%
                                                                                       6.9%
                                             5.4%

                                                                3.1%
                       2.4%




                  2003/2004                2004/2005          2005/2006              2006/2007          2007/2008

                                                               Mortality Rate




Coincident smoke inhalation injury has a major effect on morbidity and mortality in burn patients.
The age of the patient and the percentage of total body surface involved has a correlation with
survival rate. Increased age and increased percentage of total body surface results in a decrease
in burn survival rate. Functional impairment may often be a contributory factor; particularly with
burn incidents in the home. Impairment, temporary or chronic due to neurological disease or old
age, may relate to substance abuse, physical or mental disability with an inability to predict and
prevent an incident.


Until the past three years, the number of admissions has remained relatively stable, reflecting a
balance of general decline in burn injury incidence seen across North America. The pattern
however has been fluctuating recently in the Calgary Health Region. A 10.75% increase was
recorded in 2004/2005, a decrease in 2005/2006, an increase in 2006/2007 and then again a
10% increase over 20007/2008. The numbers are unpredictable and clearly it is difficult to
forecast resource needs. Further analysis of the data is underway to determine the factors
responsible and to forecast future needs.


                                                                154
Tertiary Neurorehabilitation
Program
 (Acute Care Unit 58 – Foothills Medical Centre)




      Traumatic Brain Injury Population


      Traumatic Spinal Cord Injury Population




April 1, 2007 to March 31, 2008




Prepared by:
Darren Knox, B.Sc.P.T.
Neurorehabilitation Program Facilitator
Introduction

The Tertiary Neurorehabilitation Program offers specialized rehabilitation services to
clients with impaired function secondary to a neurological injury or illness. Provision of
this service is on the 45-bed Tertiary Neurorehabilitation Unit (Acute Care Unit 58) at
Foothills Medical Centre. Clients are admitted to this unit from acute care units, other
rehabilitation facilities, and the communities within southern Alberta, southeastern British
Columbia, and southwestern Saskatchewan.

The Tertiary Neurorehabilitation Team is comprised of members from clinical nutrition,
family medicine, nursing, occupational therapy, physiatry, physiotherapy, psychology,
recreation therapy, speech-language pathology, social work, and transition services.

This report will present data on individuals with a traumatic brain injury or spinal cord
injury that received care between April 1, 2007 and March 31, 2008 on the Tertiary
Neurorehabilitation Unit.




Tertiary Neurorehabilitation Unit                                                           156
Traumatic Brain Injury Population
Client Demographics

A total of 67 clients with a traumatic brain injury diagnosis were seen in the 2007-2008
fiscal year; up 39.6% from the previous year. The median age of 38 years and
predominance of male clients were comparable with the previous year. The vast
majority of clients reside within the city of Calgary, and were admitted to the Tertiary
Neurorehabilitation Unit from an acute care unit at Foothills Medical Centre.

                                                                  2007-2008   2006-2007    2005-2006
 Total Number of
 Clients                                                              67          48          53
 Age                                Average                           39          43          42
                                    Median                            38          39          46
 Sex                                Male                             82%         81%         79%
                                    Female                           18%         19%         21%
 Region of Residence                Calgary - Urban                  84%         67%         72%
                                    Calgary - Rural                  10%        12.50%       8%
                                    Other Alberta                    6%         12.50%       17%
                                    Non-Alberta                      0%           8%         3%
 Admission Source                   FMC - Acute Care                 94%         98%         91%
                                    Other Hospital - Acute
                                    Care                            1.50%            2%       2%
                                    Home                              3%             0%       7%
                                    Continuing Care                 1.50%            0%       0%

Cause of Injury

Almost 90% of traumatic brain injury clients admitted to the Tertiary Neurorehabilitation
Unit acquired their injury from a motor vehicle collision, fall or violent cause. In
comparison with the 2006-2007 fiscal year, there has been a slight reduction in motor
vehicle collisions (9%) and an increase in violence (10%) as a cause of traumatic brain
injury.
                                                Cause of Injury (n=67)



                                         9%      3%
                                                                              MVC
                              18%                                    40%
                                                                              Fall
                                                                              Violence
                                                                              Pedestrian
                                                                              Other
                                          30%




Categorization of Traumatic Brain Injuries by Admission Glasgow Coma Scale

Glasgow Coma Scale (GCS) scores were reported on 61 of the 67 clients admitted to
the Tertiary Neurorehabilitation Unit with a traumatic brain injury. Given the admission


Tertiary Neurorehabilitation Unit                                                                  157
GCS scores, more than two thirds of these clients sustained severe brain injuries; an
increase of 15% from the previous year. This trend is worth noting, although not
statistically significant (p=0.34), given the size of the client population.

                                      Admission Glasgow Coma Scale (n=61)



                                                                    21%

                                                                                           Mild (13-15)
                                                                                           Moderate (9-12)
                                                                            10%            Severe (3-8)
                                69%




Level of Cognitive Function

Measures of cognitive function using the Rancho Los Amigos Scale are recorded upon
admission to and discharge from the Tertiary Neurorehabilitation Unit. The admission
scores varied from Levels II – VIII, while the scores on discharge varied between Levels
III – X. Scores were recorded for 64 of the 67 clients on admission, and only 61 of the
67 clients on discharge.

                                             Rancho Los Amigos Scale
                                                       Admission                Discharge
                                  Level*                 Score                    Score
                                     I                     0                        0
                                     II                    1                        0
                                    III                    2                        1
                                    IV                     4                        0
                                    V                      7                        5
                                    VI                    12                        3
                                   VII                    30                       17
                                   VIII                    8                       21
                                    IX                     0                       13
                                    X                      0                        1
                                Unreported                 3                        6
                     * Refer to www.northeastcenter.com/rancho_los_amigos_revised.htm for a description of the Rancho levels.


Pre-injury Profiles

According to the literature, individuals with a previous brain injury, history of alcohol or
drug use, pre-existing learning disability, criminal record, or highest level of education
attained at Grade 12 or less, are at a greater risk of suffering a traumatic brain injury.

Of the clients for whom this information was recorded, 80% had a level of education
equivalent or less than Grade 12. 53% of clients were recorded as having more than


Tertiary Neurorehabilitation Unit                                                                                               158
one risk factor, with no client having all five risk factors. This is a substantial difference
from the 2006-2007 fiscal year, where only 4% of clients were recorded as having more
than one risk factor.


                                            Prevalence of TBI Risk Factors (n=49)

                                           Previous TBI            9

                                     Alcohol/Drug Use                        28
                    Risk Factor



                                     Learning Disability       4

                                       Criminal Record             10

                                  Education ≤ Grade 12                              39

                                                           0            10          20        30            40      50
                                                                                  Number of Clients



Other Brain Injury Rehabilitation Indicators
For clients with traumatic brain injury, the average change in FIM™ scores1 from
admission to discharge on the Tertiary Neurorehabilitation Unit was 16.9%. The median
total length of stay for clients referred from a Foothills Medical Centre acute care unit
was 67 days. There was an upward swing in median length of stay on the Tertiary
Neurorehabilitation Unit from 34 days in 2006-07 to 40 days in 2007-08 (p=0.18).

                                                                         Average         Median            Range
                                  Admission FIM™ Scores                   86.6             98              18-122
                                  Discharge FIM™ Scores                   107.9           117              18-125
                                  % change in FIM™
                                  Scores                                 16.90%          10.30%        0-72.2%
                                  Acute LOS                               37.5             29            8-135
                                  Rehab LOS                               54.6             40            8-237
                                  Total LOS*                               92              67           24-346
                           * Only clients referred from FMC acute care units were included in this total

Rehabilitation Services Received

All clients admitted to the Tertiary Neurorehabilitation Unit with a traumatic brain injury
received Occupational, Physical, Recreation, and Speech-Language therapies. Of
these, 84% received care from Social Work, 64% from a dietician, and 55% from
Psychology.




1
  The FIM™ trade mark is owned by Uniform Data System for Medical Rehabilitation, a division of U B
Foundation Activites, Inc. FIM – The Functional Independence Measure – is an 18 item rating scale that
includes 6 activities of daily living, 2 bladder and bowel function items, 5 mobility items, and 5
cognitive/social interaction items.


Tertiary Neurorehabilitation Unit                                                                                        159
                                                                  Utilization of Rehabilitation Services (n=67)

      Number of Clients
                          80
                          70
                          60
                          50
                          40
                          30                                67                67                  67             67
                                                                                                                           56
                          20                                                                                                             37                 43
                          10
                           0
                                                                              Physiotherapy




                                                                                                                                         Psychology
                                                                                                              Pathology




                                                                                                                                                            Dietitian
                                                                                                Recreation




                                                                                                              Language
                                                         Occupational




                                                                                                                           Social Work
                                                                                                               Speech-
                                                                                                 Therapy
                                                           Therapy




                                                                                                             Discipline


Approximately three quarters of clients experienced a family conference, weekend pass,
day pass, and follow-up appointment in clinic post-discharge. Only 10% received a
home visit to assist with discharge planning. The dramatic increase in family
conferences (p<0.00001) from 2006-07 is directly attributable to a quality improvement
initiative commenced in October 2007 as part of the regional GRIDLOCC project. This
initiative was to increase client/family involvement in decision-making as regards their
care.


                                                                          Other Services Received (n=67)
                           Percent Receiving Services




                                                        90%
                                                        80%
                                                        70%
                                                        60%
                                                        50%
                                                        40%                                    78%              82%                                   84%
                                                                        72%
                                                        30%
                                                        20%
                                                        10%                                                                     10%
                                                         0%
                                                                     Family                   Weekend         Day Pass    Home Visit           Clinic
                                                                   Conference                  Pass                                          Follow-Up



Discharge Arrangements

The Supervision Rating Scale (SRS) is used to help determine the amount of support an
individual with a traumatic brain injury will require upon return to community. Admission
and discharge scores were both reported for only 43 out of 67 clients. Similar to the



Tertiary Neurorehabilitation Unit                                                                                                                                       160
previous fiscal year, scores indicate that one quarter required no supervision, while half
the clients required only part-time supervision.


                                      Supervision Rating Scale (SRS)
                                                         Admission         Discharge
                         Level of Supervision              Score             Score
                 Independent (1-2)                           7                11
                 Overnight Supervision (3)                   5                 2
                 Part-Time Supervision (4-7)                32                19
                 Full-Time Indirect Supervision (8-9)        9                10
                 Full-Time Direct Supervision (10-
                 13)                                         0                    1
                 Unreported                                 14                   24

As in the 2006-2007 fiscal year, approximately three quarters of clients returned home
upon discharge from the Tertiary Neurorehabilitation Unit and 10% continued their
recovery at another rehabilitation facility. 96% of clients returning home were living with
family or friends on discharge, and only 10% of clients returning home were referred for
Homecare services on discharge.

                                      Discharge Disposition (n=67)


                                      1%
                                   4%1%
                                 4%                                    Home
                               4%
                                                                       Rehabilitation Facility
                           10%                                         Transition Unit
                                                                       Assisted Living
                                                                       Shelter
                                                                       Acute - FMC
                                                 76%
                                                                       Acute - Other Facility




                        Homecare Services Among Those Discharged
                                       Home (n=50)


                                    10%

                                                                  Home without Homecare
                                                                  Services
                                                                  Home with Homecare
                                                                  Services

                                           90%




Tertiary Neurorehabilitation Unit                                                                161
Community Referrals

Brain Injury Rehabilitation Centre (BIRC) provides a full range of cognitive,
communication, educational, psychological, and vocational services to help clients
achieve their personal goals following concussion or mild to severe brain injury.
Association for the Rehabilitation of the Brain Injured (ARBI) is a non-profit, community-
based program offering intensive, longer-term personalized rehabilitation for individuals
with the most severe acquired brain injury requiring 24 hour care and supervision.
Community Neurorehab Services (CNS) receives funding from the Calgary Health
Region, and offers programs for clients requiring cognitive, communication, physical,
psychosocial, or vocational rehabilitation. Community Accessible Rehabilitation (CAR) is
fully funded by the Calgary Health Region, and offers services (including productivity
consultation) for clients requiring cognitive, communication, physical, and psychosocial
rehabilitation.

More than half the traumatic brain injured clients were referred to CAR, with 13% and
10% of clients being referred to CNS and rural out-patient rehabilitation respectively.


                                                   Community Rehabilitation Referrals
          Percent of Clients Referred




                                        70%                                                    60%
                                        60%
                                        50%
                                        40%
                                        30%
                                        20%                                     13%                           10%
                                        10%        1%             3%
                                         0%
                                               Brain Injury   Association     Community     Community      Rural Out-
                                              Rehabilitation     for the      Neurorehab    Accessible      Patient
                                                 Centre      Rehabilitation    Services    Rehabilitation Rehabilitation
                                                              of the Brain
                                                                 Injured




Tertiary Neurorehabilitation Unit                                                                                          162
Traumatic Spinal Cord Injury Population
Client Demographics

A total of 28 clients with a traumatic spinal cord injury diagnosis were seen in the 2007-
2008 fiscal year; up 12% from the previous year. The average age of 42 years and
predominance of male clients were comparable with the previous year. Approximately
half the clients reside within the city of Calgary, while the other half were from outside
the Calgary Health Region. All clients were admitted to the Tertiary Neurorehabilitation
Unit from an acute care unit at Foothills Medical Centre.

                                                                 2007-2008     2006-2007   2005-2006
 Total Number of
 Clients                                                             28           25          20
 Age                                Average                          42           40          44
                                    Median                           42           34          42
 Sex                                Male                            86%          76%         70%
                                    Female                          14%          24%         30%
 Region of Residence                Calgary - Urban                 46%          52%         55%
                                    Calgary - Rural                 11%          16%         5%
                                    Other Alberta                   43%          20%         30%
                                    Non-Alberta                      0%          12%         10%
 Admission Source                   FMC - Acute Care                100%         88%         95%
                                    Other Hospital - Acute
                                    Care                                0%        4%          5%
                                    Home                                0%        4%          0%
                                    Continuing Care                     0%        4%          0%

Cause of Injury

46% of traumatic spinal cord injury clients admitted to the Tertiary Neurorehabilitation
Unit acquired their injury from a motor vehicle collision, while 36% of injuries were
caused by a fall. In comparison with the 2006-2007 fiscal year, there has been an
increase in motor vehicle collisions (14%) and a slight reduction in falls (8%) as a cause
of traumatic spinal cord injury.


                                               Cause of Injury (n=28)



                                          7%     4%
                                    7%                                           MVC
                                                                         46%     Fall
                                                                                 Sports
                                                                                 Work
                                    36%                                          Other




Tertiary Neurorehabilitation Unit                                                                  163
Level and Type of Injury

A majority of clients with a traumatic spinal cord injury experienced paraplegia (57%),
with approximately equal numbers being complete and incomplete injuries. The majority
of quadriplegic injuries reported were incomplete according to the American Spinal Injury
Association (ASIA) Impairment Scale.

                                              Level and Type of Injury (n=28)


                                                                                       Quadriplegia - Complete
                                                         7%
                              32%
                                                                                       Quadriplegia - Incomplete

                                                                         36%           Paraplegia - Complete

                                        25%                                            Paraplegia - Incomplete




Spinal Cord Injury Rehabilitation Indicators

For clients with traumatic spinal cord injury, the average change in FIM™ scores from
admission to discharge on the Tertiary Neurorehabilitation Unit was 24.2%. The median
total length of stay for clients referred from a Foothills Medical Centre acute care unit
was 111.5 days. Although not statistically significant (p=0.33), there is a trend towards a
longer length of stay on the Tertiary Neurorehabilitation Unit from a median of 50 days in
2006-07 to 89 days in 2007-08.

                                                                    Average         Median              Range
                          Admission FIM™ Scores                      70.6             67                40-109
                          Discharge FIM™ Scores                      101.1           110.5              32-123
                          % change in FIM™                                                               -6.3-
                          Scores                                     24.20%         23.40%              48.4%
                          Acute LOS                                   32.6           30.5                13-65
                          Rehab LOS                                   87.6            89                12-409
                          Total LOS*                                  120.3          111.5              25-474
                      *   Only clients referred from FMC acute care units were included in this total


Rehabilitation Services Received

All clients admitted to the Tertiary Neurorehabilitation Unit with a traumatic spinal cord
injury received Occupational, Physical, and Recreation therapies. Of these, 86%
received care from Social Work, 71% from a dietician, and 68% from Psychology. No
individual with a traumatic spinal cord injury received Speech-Language Pathology
services in the 2007-2008 fiscal year.




Tertiary Neurorehabilitation Unit                                                                                  164
                                                                    Utilization of Rehabilitation Services (n=28)

                                      30
          Number of Clients
                                      25
                                      20
                                      15                          28               28         28
                                                                                                                      24
                                      10                                                                                                  19                   20
                                       5                                                                     0
                                       0
                                                              Occupational



                                                                               Physical
                                                                               Therapy




                                                                                                          Pathology


                                                                                                                      Social Work



                                                                                                                                          Psychology



                                                                                                                                                               Dietitian
                                                                                            Recreation




                                                                                                          Language
                                                                                                           Speech-
                                                                                             Therapy
                                                                Therapy




                                                                                                         Discipline


More than 80% of clients experienced a weekend pass, day pass, and follow-up
appointment in clinic post-discharge. Approximately half the clients received a family
conference and home visit to assist with discharge planning. As with the traumatic brain
injury population, there were significantly more family conferences in 2007-08 (p=0.002)
as a result of the quality improvement initiative on the Tertiary Neurorehabilitation Unit.
Additionally, there was a dramatic increase in the number of clients followed in the
Spinal Cord Injury Clinic post-discharge (p=0.04) in the 2007-08 fiscal year.


                                                                               Other Services Received (n=28)
                              Percent Receiving Services




                                                           120%
                                                           100%
                                                           80%
                                                           60%
                                                                                                                                                         96%
                                                           40%                             82%               82%
                                                                             57%
                                                           20%                                                                      43%
                                                            0%
                                                                         Family           Weekend          Day Pass   Home Visit                         Clinic
                                                                       Conference          Pass                                                        Follow-Up



Discharge Arrangements

Approximately two thirds of clients returned home upon discharge from the Tertiary
Neurorehabilitation Unit compared with three quarters the previous fiscal year. 94% of
clients returning home were living with family or friends on discharge, and 33% of clients
returning home were referred for Homecare services on discharge.


Tertiary Neurorehabilitation Unit                                                                                                                                          165
                                        Discharge Disposition (n=28)


                                           0%
                                       4% 4%
                                      4%                               Home
                                    7%                                 Acute - Other Facility
                                                                       Continuing Care
                                                                       Transition Unit
                             18%
                                                                       Rehabilitation Facility
                                                   63%
                                                                       Assisted Living
                                                                       Acute - FMC




                        Homecare Services Among Those Discharged
                                       Home (n=18)




                            33%
                                                                  Home without Homecare
                                                                  Services
                                                                  Home with Homecare
                                                 67%              Services




Community Referrals

39% and 21% of clients with a traumatic spinal cord injury respectively, were referred to
Community Accessible Rehabilitation and rural out-patient rehabilitation services upon
discharge from the Tertiary Neurorehabilitation Unit.




Tertiary Neurorehabilitation Unit                                                                166
Appendices
2007-2008 REPORT

 APPENDIX A : TRAUMA RESEARCH
 PUBLICATIONS

 APPENDIX B: TRAUMA RESEARCH
 FUNDING SUMMARY

 APPENDIX C: PROFILE OF INJURIES IN
 THE CALGARY HEALTH REGION
 REPORT
APPENDIX A
TRAUMA RESEARCH PUBLICATIONS (2007-2008)


REFERRED PUBLICATIONS

       Aljebreen AM, Romagnuolo J, Perini R, Sutherland F. Utility of endoscopic ultrasound,
       cytology and fluid carcinoembryonic antigen and CA 19-9 levels in pancreatic cystic
       lesions. World J Gastroenterol. 2007 Aug 7;13(29):3962-6.

   •   Ball CG, Lord J, Laupland KB, Gmora S, Mulloy RH, Ng AK, Schieman C, Kirkpatrick
       AW. Chest tube complications: how well are we training our residents? Can J Surg
       2007;50(6):450-8.

   •   Ball CG, Kirkpatrick AW, Smith M, Mulloy RH, Tse L, Anderson IB. Traumatic injury of
       the superior mesenteric vein: ligate, repair or shunt? Eur J Trauma Emerg Surg
       2007;5:550-2.

       Ball CG, Ball JE, Kirkpatrick AW, Mulloy RH. Equestrian injuries: incidence, injury
       patterns, and risk factors for 10 years of major traumatic injuries. Am J Surg
       2007;193(5):636-40.

       Ball CG, Kirkpatrick AW. Intra-abdominal hypertension and the abdominal compartment
       syndrome. Scand J Surg 2007;96(3):197-204.

       Ball CG, Ranson MK, Rodriguez-Galvez M, Lall R, Kirkpatrick AW. Sonographic
       depiction of posttraumatic alveolar-interstitial disease: the hand-held diagnosis of a
       pulmonary contusion. J Trauma 2008;66(3): 962.

       Ball CG, Kirkpatrick AW, Feliciano DV, Reznick R, McSwain NE. Surgeons and
       astronauts: so close, yet so far apart. Can J Surg 2008;51(4):247-50.

       Ball CG, Kirkpatrick AW, McBeth P. The secondary abdominal compartment syndrome:
       not just another post-traumatic complication. Can J Surg 2008;51(5):399-405.

       Blaivas M, Kirkpatrick A, Sustic A. Future directions and conclusions. Crit Care Med
       2007;35(5 Suppl):S305-7.

       Cheatham ML, Malbrain ML, Kirkpatrick A, Sugrue M, Parr M, De Waele J, Balogh Z,
       Leppaniemi A, Olvera C, Ivatury R, D'Amours S, Wendon J, Hillman K, Wilmer A. Results
       from the International Conference of Experts on Intra-abdominal Hypertension and
       Abdominal Compartment Syndrome. II. Recommendations. Intensive Care Med
       2007;33(6):951-62.

       Datta I, Findlay C, Kortbeek JB, Hameed SM. Evaluation of a regional trauma registry.
       Can J Surg. 2007, Jun;50(3):210-213.

       De Waele JJ, De Laet I, De Keulenaer B, Widder S, Kirkpatrick AW, Cresswell AB,
       Malbrain M, Bodnar Z, Mejia-Mantilla JH, Reis R, Parr M, Schulze R, Compano S,
       Cheatham M. The effect of different reference transducer positions on intra-abdominal
       pressure measurement: a multicenter analysis. Intensive Care Med 2008;34(7):1299-303.

       Dixon E, Schneeweiss S, Pasieka JL, Bathe OF, Sutherland F, Doig C. Mortality folloing
       liver resection in US medicare patients: does the presence of a liver transplant program
       affect outcome? J Surg Oncol. 2007 Mar 1;95(3):194-200.



                                               167
    Dyer D, Cusden J, Turner C, Boyd J, Hall R, Lautner D, Hamilton DR, Shepherd L,
    Dunham M, Bigras A, Bigras G, McBeth P, Kirkpatrick AW. The clinical and technical
    evaluation of a remote telementored telesonography system during the acute
    resuscitation and transfer of the injured patient. J Trauma 2008;65(6):1209-16.

    Garraway N, Brown DR, Nash D, Kirkpatrick A, Schneidereit NP, Van Heest R, Hwang
    H, Simons R. Active internal re-warming using a centrifugal pump and heat exchanger
    following haemorrhagic shock, surgical trauma and hypothermia in a porcine model.
    Injury 2007;38(9):1039-46.

    Goecke ME, Kirkpatrick AW, Laupland KB, Bicanic M, Findlay C. Characteristics and
    conviction rates of injured alcohol-impaired drivers admitted to a tertiary care Canadian
    Trauma Centre. Clin Invest Med 2007;30(1):26-32.

    Horne G, Ming-Lum C, Kirkpatrick AW, Parker RL. High-grade neuroendocrine
    carcinoma arising in a gastric duplication cyst: a case report with literature review. Int J
    Surg Pathol 2007;15(2):187-91.

    Jones JA, Kirkpatrick AW, Hamilton DR, Sargsyan AE, Campbell M, Melton S, Barr YR,
    Dulchavsky SA. Percutaneous bladder catheterization in microgravity. Can J Urol
    2007;14(2):3493-8.

    Karmy-Jones R, Jurkovich GJ, Velmahos GC, Kortbeek JB. Practice patterns and
    outcomes of retrievable vena cava filters in trauma patients: an AAST multicenter study. J
    Trauma. 2007, Jan;64(1):17-24; discussion 24-5.

•   Kirkpatrick AW, Jones JA, Sargsyan A, Hamilton DR, Melton S, Beck G, Nicolau S,
    Campbell M, Dulchavsky S. Trauma sonography for use in microgravity. Aviat Space
    Environ Med 2007;78(4 Suppl):A38-42.

•   Kirkpatrick AW, Colistro R, Laupland KB, Fox DL, Konkin DE, Kock V, Mayo JR,
    Nicolaou S. Renal arterial resistive index response to intraabdominal hypertension in a
    porcine model. Crit Care Med 2007;35(1):207-13.

    Kirkpatrick AW. Clinician-performed focused sonography for the resuscitation of trauma.
    Crit Care Med 2007;35(5 Suppl):S162-72.

    Kirkpatrick AW, Sustic A, Blaivas M. Introduction to the use of ultrasound in critical care
    medicine. Crit Care Med 2007;35(5; Supp):S123-S125.

    Kirkpatrick AW, Laupland KB. "The higher the abdominal pressure, the less the
    secretion of urine": another target disease for renal ultrasonography? Crit Care Med
    2007;35(5 Suppl):S206-7.

    Kirkpatrick AW, De Waele JJ, Ball CG, Ranson K, Widder S, Laupland KB. The
    secondary and recurrent abdominal compartment syndrome. Acta Clin Belg Suppl
    2007(1):60-5.

    Kirkpatrick AW, Burnstein MJ, Madoff D. Canadian Association of General Surgeons
    and American College of Surgeon’s Evidence Based Reviews: Stapled hemorrhoidopexy
    compared with conventional hemorrhoidectomy. J Am Coll Surg 2007;204:1301-3.

    Kirkpatrick AW, Ball CG, D'Amours SK, Zygun D. Acute resuscitation of the unstable
    adult trauma patient: bedside diagnosis and therapy. Can J Surg 2008;51(1):57-69.




                                             168
Kirkpatrick AW, Doarn CR, Campbell MR, Barnes SL, Broderick TJ. Manual suturing
quality at acceleration levels equivalent to spaceflight and a lunar base. Aviat Space
Environ Med 2008;79(11):1065-6.

Kirkpatrick A, Pollett W, Finlayson SRG. Canadian Association of General Surgeons
and ACS, Evidence Based Reviews in Surgery : Rural versus urban inpatient case-mix
differences in the US. J Am Coll Surg 2008;207:951-3.

Kortbeek JB, Al Turki SA, Ali J, Antoine JA, Bouillon B, Brasel K et al; Advanced trauma
life support, 8th edition, the evidence for change. Journal of Trauma. 2008,
Jun;64(6):1638-1650.

Laupland KB, Kirkpatrick AW. Isolation of Candida species from critically ill patients. J
Crit Care 2007;22(3):250-1.

Laupland KB, Kirkpatrick AW, Delaney A. Polyclonal intravenous immunoglobulin for the
treatment of severe sepsis and septic shock in critically ill adults: a systematic review and
meta-analysis. Crit Care Med 2007;35(12):2686-92.

Laupland KB, Shahpori R, Kirkpatrick AW, Stelfox HT. Hospital mortality among adults
admitted to and discharged from intensive care on weekends and evenings. J Crit Care
2008;23(3):317-24.

Laupland KB, Shahpori R, Kirkpatrick AW, Ross T, Gregson DB, Stelfox HT.
Occurrence and outcome of fever in critically ill adults. Crit Care Med 2008;36(5):1531-5.

McKay A, You I, Bigam D, Lafreniere R, Sutherland F, Ghali W, Dixon E. Impact of
surgeon training on outcomes after resective hepatic surgery. Am Surg Oncol. 2008
May;15(5):1348-55. Epub 2008 Feb 29.

McKay A, Sutherland FR, Bathe OF, Dixon E. Morbidity and mortality following
multivisceral resections in complex hepatic and pancreatic surgery. J Gastrointest Surg.
2008 Jan;12(1):86-90. Epub 2007 Aug 21.

McKay A, Cassidy D, Sutherland F, Dixon E. Clinical results of N-acetylcysteine after
major hepatic surgery: a review. J Hepatobiliary Pancreat Surg. 2008;15(5):473-8. Epub
2008 Oct 4. Review.

McBeth PB, Zygun DA, Widder S, Cheatham M, Zengerink I, Glowa J, Kirkpatrick AW.
Effect of patient positioning on intra-abdominal pressure monitoring. Am J Surg
2007;193(5):644-7.

McBeth PB, Zengerink I, Zygun D, Ranson K, Anderson I, Lall RN, Kirkpatrick AW.
Comparison of intermittent and continuous intra-abdominal pressure monitoring using an
in vitro model. Int J Clin Pract 2008;62(3):400-5.

Ng JK, Urbanski SJ, Mangat N, McKay A, Sutherland FR, Dixon E, Dowden S, Ernst S,
Bathe OF. Colorectal liver metastases contract centripetally with a response to
chemotherapy: a histomorphologic study. Cancer. 2008 Jan 15;112(2):362-71.

Parr ZE, Sutherland FR, Bathe OF, Dixon E. Pancreatic fistulae: are we making
progress? J Hepatobiliary Pancreat Surg. 2008; 15(6):563-9. Epub 2008 Nov 7. Review.

Widder S, Ranson MK, Zygun D, Knox L, Laupland KB, Laird P, Ball CG, Kirkpatrick
AW. Use of near-infrared spectroscopy as a physiologic monitor for intra-abdominal
hypertension. J Trauma 2008;64(5):1165-8.


                                        169
Zengerink I, McBeth PB, Zygun DA, Ranson K, Ball CG, Laupland KB, Widder S,
Kirkpatrick AW. Validation and experience with a simple continuous intra-abdominal
pressure measurement technique in a multidisciplinary medical/surgical critical care unit.
J Trauma 2008;64(5):1159-64.

Zengerink I, Brink PR, Laupland KB, Raber EL, Zygun D, Kortbeek JB. Needle
thoracostomy in the treatment of a tension pneumothorax in trauma patients: what size
needle? J Trauma, 2008, Jan;64(1):111-4.




                                       170
APPENDIX B
TRAUMA RESEARCH FUNDING SUMMARY (2007/2008)

     Principal          Co-investigators                        Title                     Funding Source          Time Period      Grant amount
   Investigator                                                                                                    Start/End       in dollars ($)
Clifton G. (Lead PI)   Kirkpatrick AW           National Acute Brain Injury Study:     University of Texas         Jan 2005 -       $148, 347.00
Zygun D. (Centre PI)                            Hypothermia II                         Houston Texas
Sutherland, Garnette   Duncan N, Kopp G,        Project NeuroArm: MR Compatible        Canadian Foundation for     2004 - 2008     $10,499,339.00
                       Louw D, Mesana T,        Image Guided Robot for                 Innovation (CFI)
                       Mitchell R, Pittman Q,   Microsurgery. Hotchkiss Brain
                       Ronsky J, Wyvill B,      Institute: Frontiers in Innovative
                       Anvari M, Dort J,        Robotic Surgical Technology.
                       Eliasziw M, Fielding
                       T, Forsyth P,
                       Gregoris D, Hoult D,
                       Hu R, Jennett P,
                       Kirkpatrick AW,
                       McBeth P, Sean G,
                       Sensen C, Sevick R,
                       Sharpe J, Smith K,
                       Sun Q, Tomanek B
Kirkpatrick, AW                                 Management of Occult
                                                Pneumothoraces in Mechanically         Canadian Trauma Trials      2005-2006         $5,000.00
                                                Ventilated Patients                    Collaborative
Kirkpatrick, AW        Marilyn Keaney, Mark     Gasless laparoscopy in weightless
                       Campbell, Tim            conditions during parabolic flight     Canadian Space Agency       2006-2007
                       Broderick, Chad Ball,                                                                                         $50,000.00
                       Kent Ranson

Kirkpatrick, AW        Chun R, Clarkson         Intra-abdominal hypertension with      Calgary Surgical
                       CA, Laupland KB,         severe sepsis and septic shock         Research Development          2005-            $1320.00
                                                                                       Fund
Kirkpatrick, AW        Laupland KB, Zygun       Management of Occult                   Canadian Intensive Care
                       D, Chun R, Ball CG,      Pneumothoraces in Mechanically         Foundation                  April 2006-       $16,000.00
                       Kortbeek JB, Lall R.     Ventilated Patients
Kirkpatrick AW         Turner C, Hall R,        Telesonography for Trauma Initiation   Canadian Space Agency     December 2006 -    Project Grant:
Dyer D                 Ranson K, Lautner D      of a Pilot Study for the Terrestrial                                                 $185,000 +
                                                Evaluation of a Space-Initiated                                                    $32,000 In Kind
                                                Technology                                                                          Calgary/Banff
                                                                                                                                   Funds $28,000
Kortbeek, JB           Ginting, Naora           Use of porcine small intestine sub                                  On-going        Non-Funded
                                                mucosa for open abdominal repair.
                                                ID: 20476.




                                                                              171
 Profile of Injuries in Alberta
  Health Services - Calgary
        Health Region
                         April 2007 to March 2008




Prepared by:
Sherry Elnitsky, Research Project Coordinator
Nancy Staniland, Injury Prevention and Control Leader
December, 2008
Injury Prevention and Control Services
Healthy Living, Public Health Portfolio
http://www.calgaryhealthregion.ca/injuryprevention
           Profile of Injuries in Alberta Health Services - Calgary Health Region
                                               April 2007 to March 2008

    Injuries contribute significantly to the mortality and morbidity of region residents and have a significant impact
    on health care utilization and quality of life. Injury prevention is a priority of the Healthy Living business unit of
    the Public Health Portfolio. The Injury Prevention and Control Services team works across a number of
    regional programs and services and with diverse community partners to reduce the likelihood, frequency and
    severity of injuries in the Alberta Health Services - Calgary Health Region. The Profile of Injuries in Alberta
    Health Services - Calgary Health Region (the Profile of Injuries) is updated annually in order to provide timely
    injury surveillance and to monitor the profile over time.

    The Profile of Injuries focuses on population based injury mortality and morbidity (hospitalizations and
    emergency department visits). Cost estimates of hospitalizations and emergency department visits are
    presented this year. The profile provides an analysis of cause specific injury by age and gender but
    underestimates the total burden of injury as only the most serious of injuries are included – those resulting in
    an emergency department visit, hospitalization or death. Data are not available for injuries that are presented
    at physicians’ offices and clinics or those that are treated at home.

    Methodological Notes1
•     All data are based on the December 2003 regional boundaries and were selected using ICD-10-CA codes.
•     The most recent injury mortality data available from Alberta Health & Wellness Vital Statistics are for the
      calendar year 2006. The data include deaths to region residents.
•     Injury morbidity data were obtained from Calgary Health Region Health Record Services and include
      hospital and emergency department visits at all region facilities by residents between April 2007 and March
      2008.
•     Hospital utilization is the number of discharges or separations from acute care facilities. Emergency
      department utilization is the number of admissions to emergency departments and urgent care centres (8th &
      8th Health Care Centre since 2003-04 and South Calgary Health Centre since 2005-06).
•     Hospital and emergency department data sets are not mutually exclusive. If a visit to an emergency
      department results in admission to hospital, that visit will be counted in both data sets.
•     The estimated cost of the health resources required to treat injuries in urban inpatient facilities is based on a
      case costing system that assigns costs associated with patient care and hospital overhead to individual
      patients. This is a conservative method of costing, based on only those service encounters in urban
      inpatient facilities with a most responsible diagnosis type within the injury range and for which valid cost data
      are available. The most responsible diagnosis is the one diagnosis or condition described as being the most
      responsible for the patient’s stay in hospital.
•     The average cost calculated from this method is applied to all inpatient encounters in a given year to
      determine an estimated annual cost. Since the most recent cost data available are from 2006-07, the
      average for that fiscal year was applied to 2007-08 data. It should be noted that this method will
      underestimate 2007-08 true costs.
•     The average cost of an emergency department visit is based on an estimate from Alberta Health Services -
      Capital Health. The average full cost of an emergency department visit in Capital Health in 2007-08 was
      $320 and includes diagnostic and therapeutic services as well as overhead allocations of administrative and
      support services. It does not include the physician fee for service.
•     Workplace injuries are identified by method of payment (i.e., Worker’s Compensation Board payment). As
      such, workplace injuries are also included in the overall analysis of injury cause.
•     Injury rates for 2007-08 are based on projected population estimates because actual population data for this
      period are not yet available. All rates based on previous fiscal years are defined using Alberta Health and
      Wellness population registry data.
•     The rates for 2006-07 have been updated with actual population data and may differ from those presented
      last year that were based on projected population estimates.
•     Additional historical data are presented where possible. Comparisons are based on age adjusted rates
      calculated on the same standard population (Alberta 2003-04) to reduce the potential confounding effect of
      age over time. The most recent year is compared statistically to the baseline year of 2002-03.


                                                                                                                      173
                                                                 Injury Profile Highlights
Injury Mortality
•     In 2006, there were 462 injury-related fatalities in Alberta Health Services - Calgary Health Region so that
      for every 100,000 regional residents, 38 died from an injury. The 2006 age adjusted mortality rate is not
      statistically different from the 2002 rate.
•     8% of all deaths that occurred in the region in 2006 were injury-related. This means that there was more
      than one injury death per day.
•     Overall, males were more than twice as likely as females to die from an injury and, between the ages of 25
      and 44, males were three times as likely to die from injury.
•     Another way to assess the impact of injury is by considering the potential years of life lost (PYLL); that is, the
      number of years of life lost when a person dies prematurely (in this case, before age 80). PYLL highlights
      the loss to society of early deaths.
                                  Injury-Related Mortality, Calgary Health Region Residents, 2002-20061,2
                                                                                           Injury Mortality

                             N Injury                          Age Adjusted                            Injury                           Age Adjusted
            Calendar         Related          % All            Mortality Rate                         Related            % All          PYLL Rate per
                                                                           2                                                                      3
              Year           Deaths          Deaths            per 100,000            95% CI           PYLL              PYLL             100,000                95% CI
              2002              416            7.7%                 38.3                   ±3.7        14,459             23%                  1,314              ±21.4
              2003              420            7.7%                 37.6                   ±3.6        14,177             23%                  1,259              ±20.7
              2004              440            7.9%                 38.7                   ±3.6        15,103             25%                  1,326              ±21.1
              2005              460            8.2%                 39.5                   ±3.6        15,098             24%                  1,306              ±20.8
              2006              462            7.8%                 38.2                   ±3.5        15,631             25%                  1,313              ±20.0
        1
            The data have been updated based on December 2003 regional boundaries.
        2
            2002 is considered the baseline year.

•     In 2006, there were a total of 15,631 PYLL due to injury for a crude rate of 1,294 injury-related PYLL per
      100,000 Calgary Health Region residents. There is no statistical difference between the 2006 age adjusted
      rate of injury-related PYLL compared to 2002 (baseline).
                 Proportion of Injury-Related Deaths by Age and Cause, Calgary Health Region Residents, 2006
      100%                                                                                                                       All other injuries^ (V90-V99, W20-X39,
                                                                                                                                 X50-X59, Y10-Y36, Y85-Y87, Y89)
       90%
       80%                                                                                                                       Poisoning (X40-X49)
       70%
       60%                                                                                                                       Falls (W00-W19)
       50%
       40%                                                                                                                       Violence (X85-Y09)
       30%
       20%
                                                                                                                                 Suicide (X60-X84)
       10%
         0%
                                                                                                                                 Transportation (V01-V89)
                       Under 25                     25 to 44                    45 to 64                      65+
                        (n=80)                      (n=145)                     (n=139)                     (n=98)
                          43%                         50%                          13%                        2%
                                                                Age Grouping
    ^The most common injury causes in the All Other Injuries category by age group are: Under 25: drowning (5%) and threats to breathing (incl suffocation) (3%) ; 25 to 44:
    drowning (3%); 45 to 64: drowning (4%); 65+ threats to breathing (incl suffocation) (10%). The other injury causes in each age group were relatively infrequent (less than
    3%) or unspecified.


•     The three leading causes of death for residents up to 44 years of age were transportation, suicide and
      violence. The leading causes of death for residents over the age of 44 were suicide, transportation and falls.
      Regardless of age, males were four times more likely than females to die from violence-related injuries and
      twice as likely to die from suicide and transportation-related injuries.




                                                                                                                                                                           174
Injury Morbidity
All Injuries
• About seven out of every 100 hospitalizations were injury-related and one in four emergency department
  visits was injury-related in 2007-08.
                                       Hospitalizations and Emergency Department Visits by Injury Cause, Calgary                                                                                                                       Hospitalization and Emergency Department Visit Crude Rates by Injury Cause per
                                       Health Region Residents, 2007-08                                                                                                                                                                100,000 Calgary Health Region Residents, 2007-08


                                                                     109,780
                             110,000                                                                                                                                                                10,000
                                                                                                                            Hospitalization                                                                                                                                                                    Hospitalization Rate
                             100,000                                                                                                                                                                                                                   8,756
                                                                                                                            Emergency Department Visits                                                                   9,000                                                                                Emergency Department Visit Rate
                                                   90,000
                                                                                                                                                                                                                          8,000
                                                   80,000




                                                                                                                                                                       Crude Rate per 100,000
                                                                                                                                                                                                                          7,000
    Number of Events




                                                   70,000
                                                                                                                                                                                                                          6,000
                                                   60,000
                                                                                                                                                                                                                          5,000
                                                   50,000
                                                                                                                                                                                                                          4,000
                                                   40,000
                                                                                      30,710
                                                   30,000                                                                                                                                                                 3,000                                              2,450

                                                   20,000                                                                                                                                                                 2,000
                                                                                                       10,556
                                                                7,748                                                                                                                                                                                                                         842
                                                   10,000                                                                                4,740                 3,862                                                      1,000                  618
                                                                                  3,559                                                                                                                                                                                284                                                    378                  308
                                                                                                  1,165             459 1,403      433                   301                                                                                                                             93             37 112           35                  24
                                                          0                                                                                                                                                                              0
                                                                 All Injuries^
                                                                             ^      Falls        Transportation     Suicide        Violence              Poisoning                                                                             All Injuries^         Falls            Transportation    Suicide           Violence       Poisoning
                                                               (V01-Y36, Y85-     (W00-W19)        (V01-V89)       (X60-X84)      (X85-Y09)              (X40-X49)
                                                                                                                                                                                                                                                           ^
                                                                                                                                                                                                                                             (V01-Y36, Y85-        (W00-W19)            (V01-V89)      (X60-X84)         (X85-Y09)       (X40-X49)
                                                                 Y87, Y89)                                                                                                                                                                     Y87, Y89)
                                                                                                          Injury Cause                                                                                                                                                                        Injury Cause

                             ^ This category includes Falls, Transportation, Suicide, Violence, Poisoning and all other                                                ^ This category includes Falls, Transportation, Suicide, Violence, Poisoning and all other
                             injuries.                                                                                                                                 injuries.

                                                                                                                                                                2
• There were 7,748 injury-related hospitalizations, a rate of 618 per 100,000 regional residents. This means
  that there were 21 injury-related hospitalizations in an average day.
• Overall, these injury-related hospitalizations are estimated to have cost just over 80 million dollars
  ($81,518,710) in total and almost a quarter of a million dollars a day ($220,946).
• There was a total of 109,785 injury-related emergency department visits3 resulting in a rate of 8,756 per
  100,000 regional residents. That means, on average, a resident was admitted to an emergency department
  for an injury-related event once every five minutes.
• Overall, these injury-related emergency department visits are estimated to have cost just over 35 million
  dollars ($35,131,200) and almost a hundred thousand dollars a day ($96,250).
• Rates for fall-related injuries were higher than all other injury causes for both hospital and emergency
  department utilization.
                                     Injury-Related Hospitalizations: Age and Gender Specific Utilization Rate per                                                                                   Injury-Related Emergency Department Visits: Age and Gender^ Specific Utilization
                                     100,000 Calgary Health Region Residents, 2007-08                                                                                                                Rate per 100,000 Calgary Health Region Residents, 2007-08
                                                                                                                                                 Female        Male                                                                                                                                                                  Female       Male

                                                        7000                                                                                                                                                                            20000


                                                                                                                                                                                                                                        18000
                                                        6000
                                                                                                                                                                                                                                        16000
                                                                                                                                                                                                Age-Gender Specific Rate per 100,000
                 Age-Gender Specific Rate per 100,000




                                                        5000                                                                                                                                                                            14000


                                                                                                                                                                                                                                        12000
                                                        4000

                                                                                                                                                                                                                                        10000

                                                        3000
                                                                                                                                                                                                                                         8000


                                                                                                                                                                                                                                         6000
                                                        2000

                                                                                                                                                                                                                                         4000
                                                        1000
                                                                                                                                                                                                                                         2000


                                                           0                                                                                                                                                                                 0
                                                                  0-4      5-14     15-24      25-34      35-44   45-54   55-64    65-74         75-84       85+                                                                                   0-4          5-14     15-24        25-34   35-44    45-54     55-64    65-74      75-84         85+
                                                                 (1%)     (17%)     (14%)      ( 5%)      (8%)    (10%)   (8%)     (7%)          (9%)       (14%)                                                                                (22%)         (41%)     (38%)       ( 29%)   (27%)    (23%)     (19%)    (14%)      (14%)        (16%)

                                                                                                          Age Groups                                                                                                                                                                 Age Groups
                                                                                  (% of all hospitalizations that are injury-related)                                                                                                                          (% of all emergency department visits that are injury-related)
                                                                                                                                                                       ^Gender is missing for 5 cases.

•                                                       Injury-related hospitalizations increased with age. Males were at higher risk for hospitalization until age 64
                                                        but as age increased, females experienced a greater risk for injury-related hospitalization.
•                                                       Injury accounted for a larger proportion of all hospitalizations in children, young adults and the most senior
                                                        residents.

                                                                                                                                                                                                                                                                                                                                                  175
•                                   Emergency department utilization rates were higher for younger residents and for those 85+. Males were at
                                    higher risk for injury-related emergency department visits, particularly between 15 and 44. The risk for an
                                    injury-related emergency department visit was higher for females at older ages.
•                                   Injury accounted for over a third of all emergency department visits in 5-14 years olds and 15-24 year olds
                                    and over a quarter of all visits in 25-34 and 35-44 year olds.
                                    Age Adjusted Injury-Related Hospitalization Rate per 100,000 Calgary Health                                                        Age Adjusted Injury-Related Emergency Department Visit Rate per 100,000
                                    Region Residents, 2002-03 to 2007-08                                                                                               Calgary Health Region Residents, 2002-03 to 2007-08

                                    740                                                                                                                               10000


                                                                                                                                                                      9000
                                    720

                                                                                                                                                                      8000
                                    700

                                                                                                                                                                      7000




                                                                                                                                      Age Adjusted Rate per 100,000
    Age Adjusted Rate per 100,000




                                    680
                                                                                                                                                                      6000
                                    660
                                                                                                                                                                      5000
                                    640
                                                                                                                                                                      4000

                                    620
                                                                                                                                                                      3000

                                    600
                                                                                                                                                                      2000

                                    580                                                                                                                               1000


                                    560                                                                                                                                  0
                                             2002-03        2003-04        2004-05          2005-06    2006-07              *
                                                                                                                     2007-08*                                                   2002-03        2003-04        2004-05          2005-06     2006-07          *
                                                                                                                                                                                                                                                     2007-08*
                                                                                     Year                                                                                                                               Year

                                          *Statistically lower than the 2002-03 rate (p ≤ 0.05).                                                                              *Statistically higher than the 2002-03 rate (p ≤ 0.05).


•                                   Overall, injury-related hospitalization rates have declined. Rates in 2007-08 are statistically lower than 2002-
                                    03.
•                                   The average annual cost between 2002-03 and 2007-08 for all injury-related hospitalizations was almost 74
                                    million dollars ($73,901,081).
•                                   Based this average, the total injury-related hospitalization costs for this six year period are almost half a
                                    billion dollars ($443,406,484).
•                                   Injury-related emergency department visit rates have increased. Compared to 2002-03, the rate in 2007-08
                                    was statistically higher.
•                                   In order to estimate the cost of injury-related emergency department visits, the 2007-08 estimate was
                                    applied to injury visits in the previous five years, which may overestimate real costs in earlier years.
•                                   The average annual cost between 2002-03 and 2007-08 for all injury-related emergency department visits
                                    was just over 30 million dollars ($32,059,573).
•                                   Based on this average, total injury-related emergency department visit costs for this six year period were
                                    almost 200 million dollars ($192,357,438).

All Injuries By Cause
                                                                      Injury-Related Hospitalization Rate by Injury Cause: Age Adjusted Rate
                                                                             per 100,000 Calgary Health Residents, 2002-03 to 2007-08
                                                                                                                     Age Adjusted Rate per 100,000 (95% CI)
                                                 Injury Cause
                                                                                  2002-03               2003-04                   2004-05                                            2005-06                    2006-07                    2007-08
                                              Falls                            337 (±11.2)            339 (±11.1)               310 (±10.4)                                       298 (±10.0)               302         (±9.9)           290     (±9.5)*
                                              Transportation                     92      (±5.6)        88        (±5.5)          87                             (±5.4)              89      (±5.4)            90        (±5.3)            93     (±5.3)
                                              Suicide                            59      (±4.5)        48        (±4.0)          41                             (±3.7)              37      (±3.5)            38        (±3.5)            37     (±3.3)*
                                              Violence                           33      (±3.3)        32        (±3.3)          28                             (±3.1)              36      (±3.4)            35        (±3.3)            34     (±3.2)
                                              Poisoning                          21      (±2.8)        24        (±2.9)          31                             (±3.2)              29      (±3.1)            30        (±3.1)            24     (±2.7)
                                              Workplace                          20      (±2.6)        22        (±2.7)          16                             (±2.3)              14      (±2.1)            17        (±2.3)            18     (±2.3)
                                           *Statistically different from the 2002-03 rate.

•                                   Hospitalization rates due to fall-related and suicide-related injuries were statistically lower in 2007-08
                                    compared to 2002-03.


                                                                                                                                                                                                                                                                176
                                                                Injury-Related Emergency Department Rate by Injury Cause: Age Adjusted Rate
                                                                           per 100,000 Calgary Health Residents, 2002-03 to 2007-08
                                                                                                                        Age Adjusted Rate per 100,000 (95% CI)
                                                        Injury Cause
                                                                                   2002-03                2003-04                     2004-05                                                  2005-06                   2006-07                  2007-08
                                                    Falls                       2207 (±28.1)            2426 (±29.1)            2297                                            (±28)      2565 (±29.2)           2598 (±28.9)             2502 (±28.0)*
                                                    Transportation              773     (±16.3)         817     (±16.6)         786      (±16.2)                                           862      (±16.8)        848      (±16.4)          851 (±16.2)*
                                                    Suicide                     122       (±6.4)        114      (±6.2)         104                                       (±5.9)           106          (±5.9)     107        (±5.8)         112           (±5.9)
                                                    Violence                    316       (±1.7)        353      (±1.8)         349                                       (±1.9)           374          (±1.7)     402        (±1.5)         379       (±1.7)*
                                                    Poisoning                   274       (±9.7)        334     (±10.6)         334      (±10.5)                                           315      (±10.1)        327      (±10.1)          308       (±9.7)*
                                                    Workplace                   543     (±13.5)         636     (±14.5)         658      (±14.6)                                           774      (±15.7)        892      (±16.6)          849 (±16.0)*
                                                  *Statistically different from the 2002-03 rate.

•                                           Emergency department visit rates for all injury causes except for suicide were statistically higher in 2007-08
                                            compared to 2002-03.
Falls
                                           Fall-Related Hospitalizations: Age and Gender Specific Utilization Rate per                                                           Fall-Related Emergency Department Visits: Age and Gender Specific Utilization
                                           100,000 Calgary Health Region Residents, 2007-08                                                                                      Rate per 100,000 Calgary Health Region Residents, 2007-08
                                                                                                                   Female      Male                                                                                                                           Female    Male
                                           6000                                                                                                                                 14,000



                                           5000                                                                                                                                 12,000
    Age-Gender Specific Rate per 100,000




                                                                                                                                         Age-Gender Specific Rate per 100,000




                                                                                                                                                                                10,000
                                           4000


                                                                                                                                                                                 8,000
                                           3000

                                                                                                                                                                                 6,000

                                           2000
                                                                                                                                                                                 4,000


                                           1000
                                                                                                                                                                                 2,000



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



•                                           Fall-related hospitalization rates were highest in the older population, particularly after age 65. Females
                                            were more vulnerable than males to a fall-related injury resulting in hospitalization.
•                                           The risk of a fall-related emergency department visit was highest for the youngest and oldest segments of
                                            the population. Males were at greater risk in younger age groups while females were more at risk for a fall-
                                            related emergency department visit in older age groups.
•                                           Fall-related injury visits accounted for 77% of all injury-related hospitalizations and 60% of all injury-related
                                            emergency department visits for residents 65 and older. A third (33%) of these fall-related hospitalizations
                                            were due to a hip fracture while 11% of the fall-related emergency department visits involved a hip fracture.




                                                                                                                                                                                                                                                                       177
                                                               Fall-Related Hip Fracture Hospitalization: Age Adjusted Rate per
                                                         100,000 Calgary Health Region Residents Aged 65+ Years, 2002-03 to 2007-08
                                                                                                                                                                                                                   1,2
                                                                                                          Fall-Related Hip Fracture Hospitalization
                                                                              Year                       Age adjusted Rate per
                                                                                                                                                                                                     95% CI
                                                                                                      100,000 Residents Aged 65+
                                                                           2002-03                                            625                                                                         ±49.8
                                                                           2003-04                                            690                                                                         ±51.2
                                                                           2004-05                                            646                                                                         ±48.4
                                                                           2005-06                                            570                                                                         ±44.2
                                                                           2006-07                                            555                                                                         ±42.5
                                                                           2007-08                                            486*                                                                        ±39.1
                                                                  1
                                                                    ICD-10-CA codes: S72.0-S72.2
                                                                  2
                                                                    Includes utilization in both rural and urban facilities, based on December 2003 regional boundaries.
                                                                  *Statistically different from the 2002-03 rate.

•                                            Hip fractures cause disability or death and can have a major effect on independence and on quality of life.
                                             The hospitalization rate for hip fractures due to falls for those 65 years and older is an indicator used in the
                                             Regional Falls Project, initiated in 2004-05. The rate in 2007-08 was statistically lower than both the baseline
                                             year of 2002-03 and the year the project was initiated.
Transportation
                                           Transportation-Related Hospitalizations: Age and Gender Specific Utilization Rate                                                Transportation-Related Emergency Department Visits: Age and Gender Specific
                                           per 100,000 Calgary Health Region Residents, 2007-08                                                                             Utilization Rate per 100,000 Calgary Health Region Residents, 2007-08

                                                                                                                   Female    Male                                                                                                                   Female     Male


                                            250                                                                                                                              2000


                                                                                                                                                                             1800


                                            200                                                                                                                              1600
                                                                                                                                     Age-Gender Specific Rate per 100,000
    Age-Gender Specific Rate per 100,000




                                                                                                                                                                             1400


                                            150                                                                                                                              1200


                                                                                                                                                                             1000


                                            100                                                                                                                               800


                                                                                                                                                                              600


                                             50                                                                                                                               400


                                                                                                                                                                              200


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

                                                                                  Age Groups                                                                                                                        Age Groups




•                                            Transportation was the second leading cause of injury-related hospitalization and emergency department
                                             utilization and was a particular concern among residents between 15-24 and 25-34 years of age. Emergency
                                             department utilization was also high among residents 5-14 years of age.
•                                            Males between the ages of 15-24 and 25-34 years of age were at least twice as likely as females to be
                                             hospitalized for transportation-related injuries.
•                                            Overall, the risk of a transportation injury requiring an emergency department visit or a hospitalization was
                                             highest for motor vehicles, followed by cycling and walking. A different pattern of risk is observed for school
                                             aged children 6 to 12 years old. Within this age group, risk for a transportation injury requiring either an
                                             emergency department visit or a hospitalization was highest for cycling followed by motor vehicles and
                                             walking.




                                                                                                                                                                                                                                                             178
Attempted Suicide
                                      Suicide-Related Hospitalizations: Age and Gender Specific Utilization Rate per                                                    Suicide-Related Emergency Department Visits: Age and Gender Specific
                                      100,000 Calgary Health Region Residents, 2007-08                                                                                  Utilization Rate per 100,000 Calgary Health Region Residents, 2007-08

                                                                                                                Female    Male                                                                                                                     Female    Male

                                           120                                                                                                                            400


                                                                                                                                                                          350
                                           100




                                                                                                                                 Age-Gender Specific Rate per 100,000
    Age-Gender Specific Rate per 100,000




                                                                                                                                                                          300

                                            80
                                                                                                                                                                          250


                                            60                                                                                                                            200


                                                                                                                                                                          150
                                            40

                                                                                                                                                                          100

                                            20
                                                                                                                                                                          50



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



•                                            Attempted suicide was the third leading cause of injury-related hospitalizations and the fourth leading cause
                                             of emergency department visits. Rates were highest for 15-24 year olds but, unlike the other injury causes,
                                             females were at greater risk. Females aged 15-24 were almost twice as likely as males at this age to be
                                             hospitalized and almost three times as likely to be seen at an emergency department for a suicide-related
                                             injury. This gender difference, though less extreme, is maintained across most of the lifespan.
Violence
                                           Violence-Related Hospitalizations: Age and Gender Specific Utilization Rate per                                              Violence-Related Emergency Department Visits: Age and Gender Specific
                                           100,000 Calgary Health Region Residents, 2007-08                                                                             Utilization Rate per 100,000 Calgary Health Region Residents, 2007-08
                                                                                                                Female    Male                                                                                                                     Female    Male
                                            160                                                                                                                           1800


                                            140                                                                                                                           1600
    Age-Gender Specific Rate per 100,000




                                                                                                                                                                          1400
                                                                                                                                 Age-Gender Specific Rate per 100,000




                                            120

                                                                                                                                                                          1200
                                            100

                                                                                                                                                                          1000
                                             80

                                                                                                                                                                           800
                                             60
                                                                                                                                                                           600

                                             40
                                                                                                                                                                           400

                                             20
                                                                                                                                                                           200

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



•                                            Violence-related injuries requiring hospitalization or an emergency department visit were highest for
                                             residents 15-24, 25-34, and 35-44 years of age, particularly males.
•                                            Compared to females between 15 and 44 years of age, males were six to eleven times more likely to be
                                             hospitalized for a violence-related injury and three to four times more likely to be seen in the emergency
                                             department for an injury due to violence.




                                                                                                                                                                                                                                                            179
Poisoning
                                                           Poisoning-Related Hospitalizations: Age and Gender Specific Utilization Rate per                                                         Poisoning-Related Emergency Department Visits: Age and Gender Specific
                                                           100,000 Calgary Health Region Residents, 2007-08                                                                                         Utilization Rate per 100,000 Calgary Health Region Residents, 2007-08

                                                                                                                                           Female   Male                                                                                                                                                        Female      Male

                                                                                                                                                                                                                           600
                                                            120


                                                                                                                                                                                                                           500
                                                            100




                                                                                                                                                           Age-Gender Specific Rate per 100,000
                    Age-Gender Specific Rate per 100,000




                                                                                                                                                                                                                           400
                                                             80



                                                             60                                                                                                                                                            300




                                                             40                                                                                                                                                            200




                                                             20                                                                                                                                                            100




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

•                                                           In general, poisoning-related hospitalization increased with age. Females aged 85 and older were
                                                            particularly vulnerable for a poisoning-related hospitalization.
•                                                           Rates for poisoning-related emergency department visits were highest for both males and females between
                                                            the ages of 0-4 and 15-24 years.
Workplace Injuries
                                                           Workplace-Related Hospitalizations: Age and Gender Specific Utilization Rate per                                                                Workplace-Related Emergency Department Visits: Age and Gender Specific
                                                           100,000 Calgary Health Region Residents, 2007-08                                                                                                Utilization Rate per 100,000 Calgary Health Region Residents, 2007-08

                                                                                                                                 Female      Male                                                                                                                                                             Female     Male

                                                            70                                                                                                                                                               3,000


                                                            60
                                                                                                                                                                                                                             2,500
    Age-Gender Specific Rate per 100,000




                                                                                                                                                                                    Age-Gender Specific Rate per 100,000




                                                            50
                                                                                                                                                                                                                             2,000

                                                            40

                                                                                                                                                                                                                             1,500
                                                            30

                                                                                                                                                                                                                             1,000
                                                            20


                                                                                                                                                                                                                                 500
                                                            10


                                                             0                                                                                                                                                                    0
                                                                   15-24          25-34       35-44           45-54      55-64           65-74                                                                                               15-24      25-34           35-44      45-54           55-64         65-74
                                                                                                Age Groups                                                                                                                                                                Age Groups



•                                                           For residents between the ages of 15 and 74, there was a total of 228 workplace-related injuries that
                                                            required hospitalization. This represents a rate of 18 workplace injury-related hospitalizations per 100,000
                                                            residents aged 15-74.
•                                                           In this same age range, there were 10,874 emergency department visits involving a workplace-related injury
                                                            at a rate of 867 workplace injury-related emergency department visits per 100,000 regional residents.
•                                                           Overall, males were 12 times more likely than females to experience a workplace-related injury that resulted
                                                            in hospitalization. This gender difference increased depending on age. Males under age 55 were at least
                                                            eight times and as many as 45 times more likely than females to be hospitalized for a workplace-related
                                                            injury. Though much less extreme, this gender difference was maintained between the ages of 55 and 74.
•                                                           Regardless of age, males were four times more likely to visit the emergency department for a work-related
                                                            injury. Males under the age of 45 were between four and five times more likely than females to visit the
                                                            emergency department for an injury sustained in the workplace.




                                                                                                                                                                                                                                                                                                                          180
1
  Detailed methodological details are available on request from Injury Prevention and Control Services.
2
  This represents 81% of all injury-related hospitalizations in regional facilities; 18% were to non-residents of the
  region and 1% had no information about regional status.
3
  This represents 90% of all injury-related visits to regional facilities; 9% were to non-residents of the region and
  1% had no information about regional status.




                                                                                                              181