Evaluation of trauma resources in rural northern Alberta identifies opportunities for improvement.

Background: The care of rural trauma patients in northern Alberta can be extremely challenging because of the vast geographic area, the limited access to health care facilities and the lack of adequate resources to manage severe injuries. Identifying gaps in equipment and personnel in rural centres can provide opportunities for improving the care of injured patients in these environments. We conducted a survey based on Canadian Accreditation Council quality indicators to evaluate trauma infrastructure and human resources in rural centres across northern Alberta. Methods: A standardized survey was developed to assess the availability of trauma-specific equipment and personnel across the prehospital and emergency department (ED) settings. The survey was distributed to 50 peripheral hospitals biannually from January 2017 to September 2018. Two-tailed paired t tests were used to evaluate changes in survey responses; a p value of less than 0.05 was considered statistically significant. Results: The survey response rate was 100%. By the end of the study period, there were significant improvements in the number of providers (p = 0.04), nurses (p = 0.01) and dedicated trauma resuscitation bays (p = 0.04) in the ED for managing injured patients. There were also significant increases in the availability of equipment, including advanced airway management tools (p = 0.02), rapid infusion devices (p = 0.02) and warmers (p = 0.04). Access to x-ray equipment (p = 0.03) and computed tomography (CT) scanners (p = 0.04) as well as equipment to support telehealth and teleconferencing (p = 0.04) increased during the study period. Access to, and supply of, blood products also increased significantly (p = 0.02) during the study period. Conclusion: Our study demonstrates that the trauma resources of rural health care centres may be evaluated in a standardized fashion centres, and the results point to opportunities to remedy gaps in equipment and personnel. Our methods may be applied to any trauma network that serves geographically large areas with a sparse distribution of health care facilities, to provide critical information for the optimization of resources in rural trauma.

Contexte: Les soins aux patients victimes de traumatismes en région rurale dans le nord de l'Alberta peuvent être très difficiles en raison de la superficie de la région, de l'accès limité aux établissements de santé et du manque de ressources pour soigner adéquatement les blessures graves. En repérant les lacunes en équipement et en personnel dans les établissements en région rurale, on peut créer des occasions d'améliorer les soins aux patients blessés dans ces milieux. Nous avons mené un sondage fondé sur les indicateurs de qualité du Conseil d'accréditation canadien pour évaluer les infrastructures et les ressources humaines en traumatologie dans les établissements des régions rurales du nord de l'Alberta. Méthodes: Un sondage standardisé a été créé pour évaluer la disponibilité des équipements et des ressources humaines en traumatologie en contexte préhospitalier et aux services d'urgence. Le sondage a été distribué 2 fois par année à 50 hôpitaux entre janvier 2017 et septembre 2018. Des tests t appariés ayant une hypothèse non nulle ont été utilisés pour évaluer les changements dans les réponses au sondage; les résultats ayant une valeur p < 0,05 étaient considérés comme statistiquement significatifs. Résultats: Le taux de participation au sondage était de 100 %. À la fin de la période étudiée, il y avait une amélioration significative du nombre de fournisseurs (p = 0,04), de personnel infirmier (p = 0,01) et d'espaces de réanimation réservés à la traumatologie (p = 0,04) dans les services d'urgence. Il y avait aussi une augmentation significative de la disponibilité de l'équipement, notamment des outils de prise en charge avancée des voies respiratoires (p = 0,02), des appareils de perfusion rapide (p = 0,02) et d'armoires chauffantes (p = 0,04). Les équipements de radiographie (p = 0,03) et de tomographie par ordinateur (p = 0,04) ainsi que les équipements facilitant la télémédecine et les téléconférences (p = 0,04) sont devenus plus accessibles pendant la période étudiée. Les réserves de produits sanguins et l'accès à ces produits a aussi augmenté de manière significative (p = 0,02). Conclusion: Notre étude montre que les ressources en traumatologie dans les établissements de santé en région rurale peuvent être évaluées de manière standardisée, et les résultats indiquent qu'il y a des occasions de combler les lacunes en équipement et en personnel. Notres méthodes peuvent être reproduites dans tout réseau de traumatologie couvrant un grand territoire où les établissements de santé sont dispersés, pour fournir des données critiques sur l'organisation des ressources de traumatologie en région rurale.

Use of intraosseous devices in trauma: a survey of trauma practitioners in Canada, Australia and New Zealand.

BACKGROUND: Although used primarily in the pediatric population for decades, the use of intraosseous (IO) devices in the resuscitation of severely injured adult trauma patients has recently become more commonplace. The objective of this study was to determine the experience level, beliefs and attitudes of trauma practitioners in Canada, Australia and New Zealand regarding the use of IO devices in adult trauma patients. METHODS: We administered a web-based survey to all members of 4 national trauma and emergency medicine organizations in Canada, Australia and New Zealand. Survey responses were analyzed using descriptive statistics, univariate comparisons and a proportional odds model. RESULTS: Overall, 425 of 1771 members completed the survey, with 375 being trauma practitioners. IO devices were available to 97% (353 of 363), with EZ-IO being the most common. Nearly all physicians (98%, 357 of 366) had previous training with IO devices, and 85% (223 of 261) had previously used an IO device in adult trauma patients. Most respondents (79%, 285 of 361) were very comfortable placing an IO catheter in the proximal tibia. Most physicians would always or often use an IO catheter in a patient without intravenous access undergoing CPR for traumatic cardiac arrest (84%, 274 of 326) or in a hypotensive patient (without peripheral intravenous access) after 2 attempts or 90 s of trying to establish vascular access (81%, 264 of 326). CONCLUSION: Intraosseous devices are readily available to trauma practitioners in Canada, Australia and New Zealand, and most physicians are trained in device placement. Most physicians surveyed felt comfortable using an IO device in resuscitation of adult trauma patients and would do so for indications broader than current guidelines.

CONTEXTE: Bien que le dispositif de perfusion intraosseuse soit depuis des décennies utilisé principalement chez les enfants, son utilisation lors de la réanimation d'adultes victimes de trauma grièvement blessés a récemment gagné en popularité. Notre étude vise à déterminer le niveau d'expérience, les croyances et les attitudes des spécialistes en traumatologie canadiens, australiens et néo-zélandais en ce qui concerne l'utilisation de ces dispositifs chez des patients adultes victimes de trauma. MÉTHODES: Nous avons fait parvenir un sondage Web à tous les membres de 4 organisations nationales de traumatologie et d'urgentologie au Canada, en Australie et en Nouvelle-Zélande. Les réponses ont été analysées au moyen de statistiques descriptives, de comparaisons univariées et d'un modèle à cotes proportionnelles. RÉSULTATS: Au total, parmi les 1771 personnes visées, 425 ont répondu au sondage, dont 375 spécialistes en traumatologie. De tous les répondants, 97 % avaient accès à un dispositif de perfusion intraosseuse, et le modèle EZ-IO était le plus répandu. Presque tous les médecins (98 %) avaient été formés pour utiliser cet appareil, et 85 % d'entre eux l'avaient déjà utilisé chez des adultes victimes de trauma. De plus, la plupart des répondants (79 %) étaient très à l'aise de poser un cathéter intraosseux dans la voie tibiale proximale. La plupart auraient toujours ou souvent recours à ces cathéters pour traiter un patient sans accès intraveineux subissant des manoeuvres de réanimation à la suite d'un arrêt cardiaque traumatique (84 %) ou un patient hypotendu (aucun accès veineux périphérique) sur lequel on a tenté à 2 reprises ou pendant 90 s d'établir un accès vasculaire (81 %). CONCLUSION: Les spécialistes en traumatologie canadiens, australiens et néo-zélandais ont facilement accès à des dispositifs de perfusion intraosseuse, et la plupart d'entre eux ont été formés sur leur mise en place. La plupart des répondants au sondage se sont dits à l'aise d'utiliser le dispositif lors de la réanimation d'adultes victimes de trauma et prêts à s'en servir pour traiter des cas plus variés que ce que recommandent les lignes directrices actuelles.

Increased health services use by severely obese patients undergoing emergency surgery: a retrospective cohort study.

BACKGROUND: The aim of this study was to assess perioperative outcomes in obese patients undergoing emergency surgery. METHODS: We retrospectively reviewed the charts of all adult (> 17 yr) patients admitted to the acute care emergency surgery service at the University of Alberta Hospital between January 2009 and December 2011 who had a body mass index (BMI) of 35 or higher. Patients were divided into subgroups for analysis based on "severe" (BMI 35-39.9) and "morbid" obesity (BMI ≥ 40). Multivariate logistic regression was performed to identify predictors of in-hospital mortality after controlling for confounding factors. RESULTS: Data on 111 patients (55% women, median BMI 39) were included in the final analysis. Intensive care unit (ICU) support was required for 40% of patients. Postoperative complications occurred in 42% of patients, and 31% required reoperation. Overall in-hospital mortality was 17%. Morbidly obese patients had increased rates of reoperation (40% v. 23%, p = 0.05) and increased lengths of stay compared with severely obese patients (14.5 v. 6.0 d, p = 0.09). Age (odds ratio [OR] 1.08 per increment) and preoperative ICU stay (OR 12) were significantly associated with in-hospital mortality after controlling for confounding, but BMI was not. CONCLUSION: Obese patients requiring emergency surgery represent a complex patient population at high risk for perioperative morbidity and mortality. Greater resources are required for their care, including ICU support, repeat surgery and prolonged ICU stay. Future studies could help identify predictors of reoperation and strategies to optimize nutrition, rehabilitation and resource allocation.

CONTEXTE: Cette étude avait pour objet d'évaluer les résultats périopératoires chez des patients obèses soumis à une chirurgie d'urgence. MÉTHODES: Nous avons passé en revue de manière rétrospective les dossiers de tous les patients adultes (> 17 ans) pris en charge par l'équipe de chirurgie d'urgence du Centre hospitalier de l'Université de l'Alberta entre janvier 2009 et décembre 2011 et dont l'indice de masse corporelle (IMC) était de 35 ou plus. Aux fins de l'analyse, les patients ont été répartis en 2 groupes selon qu'ils présentaient une obésité « grave ¼ (IMC 35­39,9) ou « morbide ¼ (IMC ≥ 40). Nous avons utilisé un modèle d'analyse de régression logistique multivariée pour reconnaître les prédicteurs de la mortalité perhospitalière après avoir tenu compte des facteurs de confusion. RÉSULTANTS: L'analyse finale a porté sur les données concernant 111 patients (55 % de femmes, IMC médian 39). Il a fallu faire appel à l'Unité des soins intensifs (USI) pour 40 % des patients. Des complications postopératoires sont survenues chez 42 % des patients et 31 % ont nécessité une réopération. Dans l'ensemble, la mortalité perhospitalière a été de 17 %. Les patients atteints d'obésité morbide ont présenté des taux plus élevés de réopération (40 % c. 23 %, p = 0,05) et des séjours hospitaliers plus longs comparativement aux patients souffrant d'obésité grave (14,5 c. 6,0 jours, p = 0,09). L'âge (rapport des cotes [RC] 1,08 par palier) et un séjour préopératoire à l'USI (RC 12) ont été significativement associés à la mortalité perhospitalière après contrôle des facteurs de confusion, mais non l'IMC. CONCLUSION: Les patients obèses qui ont besoin d'une chirurgie urgente forment une population de patients complexe exposée à un risque élevé de morbidité et de mortalité périopératoires. Leurs soins requièrent plus de ressources, y compris recours à l'USI, reprise de la chirurgie et prolongation du séjour à l'USI. D'autres études pourraient aider à recenser les prédicteurs des réopérations et à trouver des stratégies d'optimisation de la nutrition, de la réadaptation et de l'attribution des ressources.

A Ten year review of alcohol use and major trauma in a Canadian province: still a major problem.

BACKGROUND: Alcohol plays a significant role in major traumatic injuries. While the role of alcohol in motor vehicle trauma (MVT) is well described, its role and approaches to prevention in other injury mechanisms is less defined. METHODS: A 10 year retrospective examination of Alberta Trauma Registry (ATR) data was conducted on all major trauma patients (age ≥ 9 and ISS ≥ 12) from 2001-2010. The role and prevalence of alcohol is examined. RESULTS: Of 22,457 patients included in our study, only 60 %(n = 13,552) were screened for alcohol use. Of those screened, 38 %(n = 5,170) tested positive for alcohol with a mean blood alcohol concentration (BAC) of 39.4 ± 21.1 mmol/L. Of the positive screening tests, 82.3 % had BAC levels greater than the common legal driving limit of 17.4 mmol/L (0.08 %). Testing positive was associated with male gender (p < 0.001) and younger age (p < 0.001). The rate of positive alcohol use in major trauma increased from 20.3 % in 2001 to 24.3 % in 2010, corresponding with a screening rate increase from 51.3 % to 61.2 % over the same period. Railway incidents have the highest rate of alcohol involvement (65 %), followed by undetermined-if-accidental/self-inflicted (53.5 %) and assault (49 %); motor vehicle traffic (MVT) incidents had a frequency of 25.4 %. CONCLUSIONS: The prevalence of alcohol use in major trauma appears to be increasing in Alberta but the true extent is still underappreciated. Furthermore, the role of alcohol in non-MVT injuries is significant and deserves further attention. The vast majority of patients involved in alcohol-related trauma are legally intoxicated. Alcohol use continues to be a substantial contributor to major trauma in Alberta, and represents an important opportunity to reduce preventable injuries.

Predictors of in-hospital mortality and complications in very elderly patients undergoing emergency surgery.

INTRODUCTION: With the increasing aging population demographics and life expectancies the number of very elderly patients (age ≥ 80) undergoing emergency surgery is expected to rise. This investigation examines the outcomes in very elderly patients undergoing emergency general surgery, including predictors of in-hospital mortality and morbidity. METHODS: A retrospective study of patients aged 80 and above undergoing emergency surgery between 2008 and 2010 at a tertiary care facility in Canada was conducted. Demographics, comorbidities, surgical indications, and perioperative risk assessment data were collected. Outcomes included length of hospitalization, discharge destination, and in-hospital mortality and morbidity. Multivariable logistic regression was used to identify predictors of in-hospital mortality and complications. RESULTS: Of the 170 patient admissions, the mean age was 84 years and the in-hospital mortality rate was 14.7%. Comorbidities were present in 91% of this older patient population. Over 60% of the patients required further services or alternate level of care on discharge. American Society of Anesthesiologist Physical Status (ASA) Classification (OR 5.30, 95% CI 1.774-15.817, p = 0.003) and the development of an in-hospital complications (OR 2.51, 95% CI 1.210-5.187, p = 0.013) were independent predictors of postoperative mortality. Chronological age or number of comorbidities was not predictive of surgical outcome. CONCLUSIONS: Mortality, complication rates and post-discharge care requirements were high in very elderly patients undergoing emergency general surgery. Advanced age and medical comorbidities alone should not be the limiting factors for surgical referral or treatment. This study illustrates the importance of preventing an in-hospital complication in this very vulnerable population. ASA class is a robust tool which is predictive of mortality in the very elderly population and can be used to guide patient and family counseling in the emergency setting.

ATLS adherence in the transfer of rural trauma patients to a level I facility.

BACKGROUND: Injury sustained in rural areas has been shown to carry higher mortality rates than trauma in urban settings. This disparity is partially attributed to increased distance from definitive care and underscores the importance of proper primary trauma management prior to transfer to a trauma facility. The purpose of this study was to assess Advanced Trauma Life Support (ATLS) guideline adherence in the management of adult trauma patients transferred from rural hospitals to a level I facility. METHODS: We performed a retrospective analysis of all adult major trauma patients transferred ≥50km from an outlying hospital to a level I trauma centre from 2007 through 2009. Transfer practices were evaluated using ATLS guidelines. RESULTS: 646 patients were analyzed. Mean age was 40.5years and 94% sustained blunt injuries with a median Injury Severity Score (ISS) of 22. Median transport distance was 253km. Among all patients, there were notable deficiencies (<80% adherence) in 8 of 11 ATLS recommended interventions, including patient rewarming (8% adherence), chest tube insertion (53%), adequate IV access (53%), and motor/sensory exam (72%). Patients with higher ISS scores, and those transferred by air were more likely to receive ATLS recommended interventions. CONCLUSIONS: Key aspects of ATLS resuscitation guidelines are frequently missed during transfer of trauma patients from the periphery to level I trauma centres. Comprehensive quality improvement initiatives, including targeted education, telemedicine and trauma team training programmes could improve quality of care.

Compliance to advanced trauma life support protocols in adult trauma patients in the acute setting.

INTRODUCTION: Advanced Trauma Life Support (ATLS) protocols provide a common approach for trauma resuscitations. This was a quality review assessing compliance with ATLS protocols at a Level I trauma center; specifically whether the presence or absence of a trauma team leader (TTL) influenced adherence. METHODS: This retrospective study was conducted on adult major trauma patients with acute injuries over a one-year period in a Level I Canadian trauma center. Data were collected from the Alberta Trauma Registry, and adherence to ATLS protocols was determined by chart review. RESULTS: The study identified 508 patients with a mean Injury Severity Score of 24.5 (SD 10.7), mean age 39.7 (SD 17.6), 73.8% were male and 91.9% were involved in blunt trauma. The overall compliance rate was 81.8% for primary survey and 75% for secondary survey. The TTL group compared to non-TTL group was more likely to complete the primary survey (90.9% vs. 81.8%, p = 0.003), and the secondary survey (100% vs. 75%, p = 0.004). The TTL group was more likely than the non-TTL group to complete the following tasks: insertion of two large bore IVs (68.2% vs. 57.7%, p = 0.014), digital rectal exam (64.6% vs. 54.7%, p = 0.023), and head to toe exam (77% vs. 67.1%, p = 0.013). Mean times from emergency department arrival to diagnostic imaging were also significantly shorter in the TTL group compared to the non-TTL group, including times to pelvis xray (mean 68min vs. 107min, p = 0.007), CT chest (mean 133min vs. 172min, p = 0.005), and CT abdomen and pelvis (mean 136min vs. 173min, p = 0.013). Readmission rates were not significantly different between the TTL and non-TTL groups (3.5% vs. 4.5%, p = 0.642). CONCLUSIONS: While many studies have demonstrated the effectiveness of trauma systems on outcomes, few have explored the direct influence of the TTL on ATLS compliance. This study demonstrated that TTL involvement during resuscitations was associated with improved adherence to ATLS protocols, and increased efficiency (compared to non TTL involvement) to diagnostic imaging. Findings from this study will guide future quality improvement and education for early trauma management.

Quality of life and long-term outcomes of octo- and nonagenarians following acute care surgery: a cross sectional study.

BACKGROUND: While advanced age is often associated with poorer surgical outcomes, long-term age-related health status following acute care surgery is unknown. The objective of our study was to assess post-operative cognitive impairment, functional status, and quality of life in elderly patients who underwent emergency surgery. METHODS: We identified 159 octo- and nonagenarians who underwent emergency surgery between 2008 and 2010 at a single tertiary hospital. Patients were grouped into three cohorts: 1, 2, and 3 years post-operative. We conducted a survey in 2011, with octo- and nonagenarians regarding the impact of emergency surgical procedures. Consenting participants responded to four survey questionnaires: (1) Abbreviated Mental Test Score-4, (2) Barthel Index, (3) Vulnerable Elders Survey, and (4) EuroQol-5 Dimensional Scale. RESULTS: Of the 159 octo- and nonagenarians, 88 (55.3%) patients were alive at the time of survey conduction, and 55 (62.5%) of the surviving patients consented to participate. At 1, 2, and 3 years post-surgery, mortality rates were 38.5%, 44.7%, and 50.0%, respectively. More patients had cognitive impairments at 3 years (33.3%) than at 1 (9.5%) and 2 years (9.1%) post-operatively. No statistical difference in the ability to carry out activities of daily living or functional decline with increasing time post-operatively. However, patients perceived a significant health decline with the greater time that passed following surgery. CONCLUSIONS: Our study showed that half of the patients over the age of 80 are surviving up to 3 years post-operatively. While post-operative functional status appears to be stable across the 3 cohorts of patients, perceived health status declines over time. Understanding the long-term post-operative impact on cognitive impairment, functional status, and quality of life in elderly patients who undergo acute care surgery allows health care professionals to predict their patients' likely post-operative needs.