Development and Validation of Quality Criteria for Providing Patient- and Family-centered Injury Care.

OBJECTIVE: The aim of this study was to develop and evaluate the content validity of quality criteria for providing patient- and family-centered injury care. BACKGROUND: Quality criteria have been developed for clinical injury care, but not patient- and family-centered injury care. METHODS: Using a modified Research AND Development Corporation (RAND)/University of California, Los Angeles (UCLA) Appropriateness Methodology, a panel of 16 patients, family members, injury and quality of care experts serially rated and revised criteria for patient- and family-centered injury care identified from patient and family focus groups. The criteria were then sent to 384 verified trauma centers in the United States, Canada, Australia, and New Zealand for evaluation. RESULTS: A total of 46 criteria were rated and revised by the panel over 4 rounds of review producing 14 criteria related to clinical care (n = 4; transitions of care, pain management, patient safety, provider competence), communication (n = 3; information for patients/families; communication of discharge plans to patients/families, communication between hospital and community providers), holistic care (n = 4; patient hygiene, kindness and respect, family access to patient, social and spiritual support) and end-of-life care (n = 3; decision making, end-of-life care, family follow-up). Medical directors, managers, or coordinators representing 254 trauma centers (66% response rate) rated 12 criteria to be important (95% of responses) for patient- and family-centered injury care. Fewer centers rated family access to the patient (80%) and family follow-up after patient death (65%) to be important criteria. CONCLUSIONS: Fourteen-candidate quality criteria for patient- and family-centered injury care were developed and shown to have content validity. These may be used to guide quality improvement practices.

Ten years of all-terrain vehicle injury, mortality, and healthcare costs.

BACKGROUND: All-terrain vehicles (ATVs) are increasing in popularity worldwide. The province of Alberta accounts for 25% of Canadian ATV sales. This study describes the epidemiology, outcomes, and associated healthcare costs for a decade of ATV traumatic injury incidents. METHODS: This is a retrospective population based cohort study using two provincial databases: the Alberta Trauma Registry and the Office of the Chief Medical Examiner of Alberta. Data for individuals aged 18 years or older with Injury Severity Score ≥ 12 or deaths between April 1, 1998, and March 31, 2008 were included. Healthcare costs were extrapolated using figures from a Level I trauma center. RESULTS: ATV incidents resulted in 459 serious trauma cases, 395 trauma center admissions (a total of 4,117 days), and a 17% mortality rate. Postdischarge care was required for nearly 30% of patients. Male patients aged 18 years to 19 years had the highest incidence (6.5 of 100,000 people). Head, neck, and cervical spine injuries were most common (59%) and predictive of mortality (relative risk [RR], 2.19; interquartile range [IQR], 1.35-3.54; p = 0.001). Vehicle rollovers (RR, 2.75; IQR, 1.13-6.70; p = 0.01), vehicle ejection (RR, 4.18; IQR, 1.70-10.32; p = 0.000), alcohol intake (RR, 2.33; IQR, 1.52-3.56; p = 0.000), helmet use (RR, 1.82; IQR, 1.11-3.02; p = 0.01), and incident location were predictive of mortality. CONCLUSIONS: Increasing rates of ATV-related serious trauma and death are described in young males riding without helmets after consuming alcohol. Serious injuries contributed to healthcare costs in excess of $6.5 million USD. Predictors of mortality include rider behaviors and mechanical factors. Prevention should include rider education and industry measures to improve ATV stability.

Access to trauma systems in Canada.

BACKGROUND: Trauma is a leading cause of morbidity, potential years of life lost and health care expenditure in Canada and around the world. Trauma systems have been established across North America to provide comprehensive injury care and to lead injury control efforts. We sought to describe the current status of trauma systems in Canada and Canadians' access to acute, multidisciplinary trauma care. METHODS: A national survey was used to identify the locations and capabilities of adult trauma centers across Canada and to identify the catchment populations they serve. Geographic information science methods were used to map the locations of Level I and Level II trauma centers and to define 1-hour road travel times around each trauma center. Data from the 2006 Canadian Census were used to estimate populations within and outside 1-hour access to definitive trauma care. RESULTS: In Canada, 32 Level I and Level II trauma centers provide definitive trauma care and coordinate the efforts of their surrounding trauma systems. Most Canadians (77.5%) reside within 1-hour road travel catchments of Level I or Level II centers. However, marked geographic disparities in access persist. Of the 22.5% of Canadians who live more than an hour away from a Level I or Level II trauma centers, all are in rural and remote regions. DISCUSSION: Access to high quality acute trauma care is well established across parts of Canada but a clear urban/rural divide persists. Regional efforts to improve short- and long-term outcomes after severe trauma should focus on the optimization of access to pre-hospital care and acute trauma care in rural communities using locally relevant strategies or novel care delivery options.

Motorcycle-related trauma in Alberta: a sad and expensive story.

BACKGROUND: Trauma caused by motorcycle-related injuries is extensive, expensive and increasing. Recent American literature reported that in 2004 the chance of a motorcyclist dying was 34 times greater than that for someone using any other motor vehicle for every mile travelled. In the United Kingdom a motorcyclist is killed or seriously injured every 665,894 km, compared with 18,661,626 km for cars. If this pattern is repeated in Canada, then this information should be in the public domain to support initiatives for injury prevention. METHODS: We gathered and analyzed retrospective population data on the injury patterns of adult motorcyclists and other adult motor vehicle drivers and passengers across Alberta from Apr. 1, 1995, to Mar. 31, 2006. We collected data from 3 Alberta sources: the Alberta Trauma Registry, the Alberta Office of the Chief Medical Examiners and the Government of Alberta Department of Infrastructure and Transportation. We compared the numbers and causes of crashes, injuries and deaths, as well as the acute care costs on the roads, and specifically compared motorcycle-related injuries to all other motor vehicle-related injuries. RESULTS: There were 70,605 registered motorcycles and 2,748,204 other registered motor vehicles in Alberta during the study period. During these 11 years, there were 286 motorcyclists killed and 712 were severely injured, representing a total of 998 injuries and deaths. There was 5386 deaths related to other motor vehicles and 6239 severe injuries, for a total of 11,625 injuries and deaths. This represents a percentage of 1.4% of all registered motorcycles and 0.4% of all other registered motor vehicles (3.5 times more motorcyclist injuries). The impact on the health care system can be measured in several ways. During the period of this study, motorcyclists accounted for 10,760 bed days. Assuming the patient was not admitted to intensive care, each admission cost Can$9200 (average in 2008). CONCLUSION: Analysis of the data shows that motorcyclists are more than 3.5 times more likely to get injured or die than other motor vehicle drivers. All of the injuries in motorcyclists occurred during the summer months, leading to an adjusted risk of almost 8 times compared with that of the motor vehicle driver.

User's perceptions of remote trauma telesonography.

We established a pilot tele-ultrasound system between a rural referring hospital and a tertiary care trauma centre to facilitate telementoring during acute trauma resuscitations. Over a 12-month period, 23 tele-ultrasound examinations were completed. The clinical protocol examined both the Focused Assessment with Sonography for Trauma (FAST) and the Extended FAST (EFAST) for pneumothoraxes. Twenty of the examinations were conducted during acute trauma resuscitations and three during live patient simulations. FAST examinations were completed in all 23 cases and EFAST examinations in 17 cases. There were 18 clinical users, of whom 14 completed a survey (76% response rate). Overall, 93% of respondents were either satisfied or very satisfied with the telemedicine interaction and agreed or strongly agreed that the technology could potentially benefit injured patients in the far north of Canada. In addition, 93% of the respondents felt that the project had improved collegiality between the two institutions involved. The majority of respondents (71%) agreed or strongly agreed that the project had improved their ultrasound skills. We believe that as further experience is obtained, tele-ultrasound will prove to be an important aid to the care of remotely injured and ill patients.

The clinical and technical evaluation of a remote telementored telesonography system during the acute resuscitation and transfer of the injured patient.

BACKGROUND: Ultrasound (US) has an ever increasing scope in the evaluation of trauma, but relies greatly on operator experience. NASA has refined telesongraphy (TS) protocols for traumatic injury, especially in reference to mentoring inexperienced users. We hypothesized that such TS might benefit remote terrestrial caregivers. We thus explored using real-time US and video communication between a remote (Banff) and central (Calgary) site during acute trauma resuscitations. METHODS: A existing internet link, allowing bidirectional videoconferencing and unidirectional US transmission was used between the Banff and Calgary ERs. Protocols to direct or observe an extended focused assessment with sonography for trauma (EFAST) were adapted from NASA algorithms. A call rota was established. Technical feasibility was ascertained through review of completed checklists. Involved personnel were interviewed with a semistructured interview. RESULTS: In addition to three normal volunteers, 20 acute clinical examinations were completed. Technical challenges requiring solution included initiating US; audio and video communications; image freezing; and US transmission delays. FAST exams were completed in all cases and EFASTs in 14. The critical anatomic features of a diagnostic examination were identified in 98% of all FAST exams and a 100% of all EFASTs that were attempted. Enhancement of clinical care included confirmation of five cases of hemoperitoneum and two pneumothoraces (PTXs), as well as educational benefits. Remote personnel were appreciative of the remote direction particularly when instructions were given sequentially in simple, nontechnical language. CONCLUSIONS: The remote real-time guidance or observation of an EFAST using TS appears feasible. Most technical problems were quickly overcome. Further evaluation of this approach and technology is warranted in more remote settings with less experienced personnel.

Factors related to the failure of radiographic recognition of occult posttraumatic pneumothoraces.

PURPOSE: Although posttraumatic pneumothoraces (PTXs) are common and potentially life threatening, the supine chest radiograph (CXR) is an insensitive test for their detection. Computed tomography (CT) often identifies occult pneumothoraces (OPTXs). Previous descriptions of OPTX topography have been poor. Our purpose was to define their distribution and aid in the targeting of thoracic ultrasound. METHODS: Posttraumatic supine CXRs and CTs were reviewed for occult, overt, and residual PTXs. PTXs were compared according to their apical, basal, anterior, lateral, medial, and posterior components. A comparative size index was calculated. RESULTS: Among 761 patients, 338 CT scans revealed 103 PTXs in 89 patients; 55% were OPTXs. OPTXs were apical (57%), basal (41%), anterior (84%), lateral (24%), and medial (27%), with 0% posterior. CONCLUSIONS: CXR missed over half of all PTXs. OPTXs had a greater anterior versus lateral (nearly 4-fold) and both basal and apical versus lateral (2-fold) distribution. OPTXs are often located at easily accessible sonographic windows.