Trauma resident exposure in Canada and operative numbers (TraumaRECON): a national multicentre retrospective review of operative and nonoperative trauma teaching.

BACKGROUND: General surgeons play an important role in the provision of trauma care in Canada and the current extent of their trauma experience during training is unknown. We sought to quantify the operative and nonoperative educational experiences among Canadian general surgery trainees. METHODS: We conducted a multicentre retrospective study of major operative exposures experienced by general surgery residents, as identified using institutional trauma registries and subsequent chart-level review, for 2008-2018. We also conducted a site survey on trauma education and structure. RESULTS: We collected data on operative exposure for general surgery residents from 7 programs and survey data from 10 programs. Operations predominantly occurred after hours (73% after 1700 or on weekends) and general surgery residents were absent from a substantial proportion (25%) of relevant trauma operations. The structure of trauma education was heterogeneous among programs, with considerable site-specific variability in the involvement of surgical specialties in trauma care. During their training, graduating general surgery residents each experienced around 4 index trauma laparotomies, 1 splenectomy, 1 thoracotomy, and 0 neck explorations for trauma. CONCLUSION: General surgery residents who train in Canada receive variable and limited exposure to operative and nonoperative trauma care. These data can be used as a baseline to inform the application of competency-based medical education in trauma care for general surgery training in Canada.

Paramedic to trauma team verbal handover optimization - a complex interaction.

BACKGROUND: Handover to the trauma team is crucial to trauma care. The emergency medical services (EMS) report must be concise, contain key details, and be time-limited. Effective handover is difficult, often occurring between unfamiliar teams, in chaotic environments, and without standardization. We aimed to evaluate handover formats in comparison to ad-lib communication during trauma handover. METHODS: We conducted a single-blind randomized simulation trial evaluating 2 structured handover formats. Paramedics randomly assigned to ad-lib, ISOBAR (identify, situation, observations, background, agreed plan, and readback) or IMIST (identification, mechanism/medical complaint, injuries/ information about complaint, signs, treatments) handover formats underwent scenarios in an ambulance, then transfer to the trauma team. Assessment of handovers was completed by the trauma team and by experts using audiovisual recordings. RESULTS: Twenty-seven simulations were conducted, 9 for each handover format. Participant ratings of the usefulness of the IMIST and ISOBAR formats were 9/10 and 7.5/10, respectively (p = 0.097). Quality of the handover was deemed higher by team members when a statement of objective vital signs and a logical format was used. Handovers delivered with confidence, directed and summarized by a trauma team leader, before physical patient transfer, and without interruption were identified as having the highest quality. The type of format was not a significant contributor to handover; however, we identified a matrix of factors affecting the quality of trauma handover. CONCLUSION: Our study shows agreement by prehospital and hospital personnel that a standardized handover tool is preferred. A brief confirmation of physiologic stability, including vital signs, limiting distractions, and team summarization improves handover effectiveness.

The next frontier of acute care general surgery: fellowship training.

Acute care surgery (ACS) is an area of surgical specialization within general surgery and a model for clinical care delivery that has proliferated over the last 2 decades. Models of ACS in Canada exist in both academic and community settings and are used to manage patients in need of emergency general surgery (EGS) care, with or without the provision of trauma care. The implementation of the ACS model has changed the landscape of patient care, surgical education and the workforce, providing an option for some general surgeons to exclude EGS care from their regular practice. The rise of ACS as a concentration of surgical skill and content expertise has resulted in the establishment of dedicated ACS fellowship training programs. This is a landmark in the evolution of general surgery, as well as a stepping stone on the path to improving patient care, surgical education and scholarly endeavour in this field.

Operating room use for emergency general surgery cases: analysis of the Patterns of Complex Emergency General Surgery in Canada study.

BACKGROUND: Access to the operating room (OR) is variable among emergency general surgery (EGS) services, with some having dedicated EGS ORs, and others only a shared queue. Currently in Canada, only a limited number of acute care surgery services have dedicated daytime operating room (OR) access; hence, we aimed to describe the burden of after-hours EGS operating in Canada and differences associated with OR access. METHODS: In this multicentre retrospective cohort study, we used data from a previously conducted study designed to evaluate nonappendiceal, nonbiliary disease across 8 Canadian hospitals. We performed a secondary analysis to describe booking priorities and timing of operative interventions, compare sites with and without access to a dedicated EGS daytime OR, and identify differences in morbidity and mortality based on timing of operative intervention. RESULTS: Among 1244 patients, operations were performed during weekday daytime in 521 cases (41.9%), in the evening in 279 (22.4%), on the weekend in 293 (23.6%) and overnight in 151 (12.1%). Operating room booking priority was more than 2 hours to 8 hours in 657 cases (52.8%), more than 8 hours to 24 hours in 334 (26.9%) and more than 24 hours to 48 hours in 253 (20.3%). Substantial variation in booking priority was observed for the same preoperative diagnoses. Sites with dedicated EGS ORs performed a greater proportion of cases during daytime versus overnight compared to sites without dedicated EGS ORs (198/237 [83.5%] v. 323/435 [74.2%], p = 0.006). No significant differences in outcome were found between cases performed during the daytime, evening and overnight. CONCLUSION: We found considerable variation in OR booking priority within the same preoperative diagnoses among EGS patients in Canada. Sites with dedicated EGS ORs performed more cases during weekday daytime compared to sites without dedicated EGS ORs; however, this study showed no evidence of compromised outcomes based on OR timing.

Resuscitative endovascular balloon occlusion of the aorta in Canada: a context-specific position paper from the Canadian Collaborative for Urgent Care Surgery (CANUCS).

SummaryResuscitative endovascular balloon occlusion of the aorta (REBOA) is a well-described intervention for noncompressible torso hemorrhage. Several Canadian centres have included REBOA in their hemorrhagic shock protocols. However, REBOA has known complications and equipoise regarding its use persists. The Canadian Collaborative on Urgent Care Surgery (CANUCS) comprises surgeons who provide acute trauma care and leadership in Canada, with experience in REBOA implementation, use, education and research. Our goal is to provide evidence- and experience-based recommendations regarding institutional implementation of a REBOA program, including multidisciplinary educational programs, attention to device and care pathway logistics, and a robust quality assurance program. This will allow Canadian trauma centres to maximize patient benefits and minimize risks of this potentially life-saving technology.

Failure to rescue in emergency general surgery in Canada.

BACKGROUND: The risk of death after a postoperative complication - known as failure to rescue (FTR) - has been proposed to be superior to traditional benchmarking outcomes, such as complication and mortality rates, as a measure of system quality. The purpose of this study was to identify the current FTR rate in emergency general surgery (EGS) centres across Canada. We hypothesized that substantial variability exists in FTR rates across centres. METHODS: In this multicentre retrospective cohort study, we performed a secondary analysis of data from a previous study designed to evaluate operative intervention for nonappendiceal, nonbiliary disease by 6 EGS services across Canada (1 in British Columbia, 1 in Alberta, 3 in Ontario and 1 in Nova Scotia). Patients underwent surgery between Jan. 1 and Dec. 31, 2014. We conducted univariate analyses to compare patients with and without complications. We performed a sensitivity analysis examining the mortality rate after serious complications (Clavien-Dindo score 3 or 4) that required a surgical intervention or specialized care (e.g., admission to intensive care unit). RESULTS: A total of 2595 patients were included in the study cohort. Of the 206 patients who died within 30 days, 145 (70.4%) experienced a complication before their death. Overall, the mortality rate after any surgical complication (i.e., FTR) was 16.0%. Ranking of sites by the traditional outcomes of complication and mortality rates differed from the ranking when FTR rate was included in the assessment. CONCLUSION: There was variability in FTR rates across EGS services in Canada, which suggests that there is opportunity for ongoing quality-improvement efforts. This study provides FTR benchmarking data for Canadian EGS services.

Management of vascular trauma across Canada: A cohort study with implications for practice.

BACKGROUND: The aim of this study was to provide a description of vascular trauma and its management at trauma centers across Canada. METHODS: This retrospective cohort study evaluated patients from 8 Canadian level 1 trauma centers (2011-2015). Medical records were queried to identify adult patients who survived to hospital with major vascular injury. Major vascular injury was defined as injury to named arterial or venous vessels in the legs, arms torso, and neck. Data collected included patient demographics, injury mechanism, injury details, management and clinical outcomes. RESULTS: A total of 1330 patients were included. Patients were 76% male with a mean age of 43 (SD 18.8). Reported injuries were 63% blunt, 36% penetrating, and the remainder mixed. The most common specific mechanisms of injury were motor vehicle collision (36%), stabbing (26%), and falls (16%), with gunshot injuries accounting for <5%. Pre-hospital tourniquets were applied in 27 patients (2%). The mean Injury Severity Score (ISS) was 24 (SD 14.5). We identified injuries to named vessels of the neck (32%), thorax (23%), abdomen and pelvis (27%), upper extremity (14%) and lower extremity (10%). Specific vascular injuries included transection (50%), complete occlusion (11%), partial occlusion (39%), and pseudoaneurysm formation (11%). Injuries were managed non-operatively in 32%, with definitive open surgical management (24%), endovascular management (9%) and with damage control techniques in the operating room (3%). Amputation occurred in 10% of lower extremity and 5% of upper extremity injuries. Responsibility for vascular injury management was undertaken by a wide variety of specialists (n = 17). Overall, in-hospital mortality was 13%, and 2% of patients underwent amputation. CONCLUSION: This study describes the nature and management of vascular injuries across Canada. The variability in injury mechanisms, management strategies, specialty responsible for management, and outcomes have important implications for practice change and knowledge translation.

The Impact of the Affordable Care Act on Trauma Outcomes in At-Risk Groups: An Interrupted Time Series Analysis with Control Group.

OBJECTIVE: Analyze the impact of the Affordable Care Act (ACA) on trauma outcomes at a population level and within at-risk subgroups. BACKGROUND: Trauma disproportionately affects the uninsured. Compared to the insured, uninsured patients have worse functional outcomes and increased mortality. The goal of the ACA was to increase access to insurance. METHODS: An interrupted time series was conducted using data from the National Inpatient Sample database between 2011 and 2016. Data from Alberta, Canada was used as a control group. Mortality, length of stay, and probability of discharge home with or without home health care was examined using monthly time intervals, with January 2014 as the intervention time. Single and multiple group interrupted time series were conducted. Subgroup analyses were conducted using income quartiles and race. RESULTS: After the intervention, there was a monthly reduction in mortality of 0.0148% ( P < 0.01) in the American cohort: there was no change in the Canadian cohort. The White subgroup experienced a mortality reduction: the non-White subgroup did not. There was no significant change in length of stay or discharge home rate at a population level. There was a monthly increase in the probability of discharge with home health (0.0247%: P < 0.01); this was present in the lower-income quartiles and both race groups. The White subgroup had a higher rate of utilization of home health pre-ACA, and this discrepancy persisted post-ACA. CONCLUSIONS: The ACA is associated with improved mortality and increased use of home health services. Discrepancies amongst racial groups and income quartiles are present.

Multidisciplinary, multisite trauma team training during COVID-19: lessons from the first virtual E-S.T.A.R.T.T. course.

Trauma care delivery is a complex team-based task that requires deliberate practice. The COVID-19 pandemic has not diminished the importance of excellent trauma team dynamics. However, the pandemic hampers our ability to gather safely and train together. A mitigating solution is the provision of high-fidelity simulation training in a virtual setting. The Simulated Trauma and Resuscitation Team Training (S.T.A.R.T.T.) course has provided multidisciplinary trauma team members with skills in crisis resource management (CRM) for nearly 10 years. It has promoted collaborative learning from coast to coast, as the course typically runs at our national surgical and trauma meetings. In response to COVID-19 challenges, the course content has been modified to virtually connect 2 centres in different provinces simultaneously. High participant satisfaction suggests that the new virtual E-S.T.A.R.T.T course is able to continue to help providers develop important CRM skills in a multidisciplinary setting while remaining compliant with COVID-19 safety precautions.

A gap analysis of the potential use of resuscitative endovascular balloon occlusion of the aorta (REBOA) in trauma at two major Canadian trauma centers.

OBJECTIVE: Uncontrolled hemorrhage poses significant morbidity and mortality among injured patients. Resuscitative endovascular balloon occlusion of the aorta (REBOA) utilizes a rapidly-administered minimally invasive transfemoral balloon catheter that is inflated for aortic occlusion, allowing for time to arrange definitive surgical or angiographic intervention. As indications for its use continue to evolve, this study sought to evaluate whether there is a potential need for REBOA implementation in two high-volume trauma centers in Edmonton. METHODS: Patient data within our provincial trauma registry was reviewed between 2015 and 2017 to identify major trauma patients (Injury Severity Score ≥ 12). Patients eligible for REBOA included patients with blunt or penetrating trauma to the torso or pelvis, AND death prior to discharge; and patients taken to the operating room or interventional radiology suite within 4 h of arrival. Charts were reviewed to determine if patients met current conventional criteria for REBOA. RESULTS: Out of 3415 trauma patients during our study period, 237 patients met the registry screen as potentially eligible for REBOA. After primary researcher review, 67 patients underwent full chart review and then 2 trauma surgeons determined that 38 (1.1% of the study population) met criteria for deploying REBOA. CONCLUSION: A small but significant number of trauma patients at the two trauma centers were identified as potential candidates for REBOA use. Implementation of a REBOA program should be done in alignment with existing clinical practice guidelines and professional society recommendations.

RéSUMé: OBJECTIF: L'hémorragie incontrôlée entraîne une morbidité et une mortalité importantes chez les patients blessés. Le clampage aortique par sonde d'occlusion aortique endovasculaire (resuscitative endovascular balloon occlusion of the aorta [REBOA]) utilise un cathéter à ballonnet transfémoral mini-invasif à administration rapide qui est gonflé pour l'occlusion aortique, ce qui laisse le temps d'organiser une intervention chirurgicale ou angiographique définitive. Alors que les indications de son utilisation continuent d'évoluer, cette étude a cherché à évaluer s'il y avait un besoin potentiel de mise en œuvre de REBOA dans deux centres de traumatologie à haut volume à Edmonton. MéTHODES: Les données sur les patients dans notre registre provincial des traumatismes ont été examinées entre 2015 et 2017 afin d'identifier les patients traumatisés majeurs (Score de gravité des blessures ≥ 12). Les patients éligibles au REBOA comprenaient des patients présentant un traumatisme contondant ou pénétrant au torse ou au bassin, ET le décès avant la sortie; et les patients conduits à la salle d'opération ou à la salle de radiologie interventionnelle dans les 4 heures suivant leur arrivée. Les graphiques ont été examinés pour déterminer si les patients répondaient aux critères conventionnels actuels de REBOA. RéSULTATS: Sur les 3 415 patients traumatisés pendant notre période d'étude, 237 patients ont répondu à l'examen du registre comme étant potentiellement éligibles pour le REBOA. Après examen par le chercheur principal, soixante-sept patients ont été soumis à un examen complet de leur dossier, puis deux chirurgiens traumatologues ont déterminé que 38 (1,1 % de la population étudiée) répondaient aux critères de déploiement de la REBOA. CONCLUSION: Un nombre restreint mais significatif de patients traumatisés dans les deux centres de traumatologie a été identifié comme des candidats potentiels à l'utilisation de REBOA. La mise en œuvre d'un programme REBOA doit se faire en conformité avec les directives de pratique clinique existantes et les recommandations de la société professionnelle.

Time to operating room matters in modern management of pancreatic injuries: A national review on the management of adult pancreatic injury at Canadian level 1 trauma centers.

BACKGROUND: Pancreatic injuries are rare, difficult to diagnose, and complex to manage despite multiple published guidelines. This study was undertaken to evaluate the current diagnosis and management of pancreatic trauma in Canadian trauma centers. METHODS: This is a multi-institutional retrospective study from 2009 to 2014 including patients from eight level 1 trauma centers across Canada. All patients with a diagnosis of pancreatic trauma were included. Demographics, injury characteristics, vital signs on admission, and type of management were collected. Outcomes measured were mortality and pancreas-related morbidity. RESULTS: Two hundred seventy-nine patients were included. The median age was 29 years (interquartile range, 21-43 years), 72% were male, and 79% sustained blunt trauma. Pancreatic injury included the following grades: I, 26%; II, 28%; III, 33%; IV, 9%; and V, 4%. The overall mortality rate was 11%, and the pancreas-related complication rate was 25%. The majority (88%) of injuries were diagnosed within 24 hours of injury, primarily (80%) with a computed tomography scan. The remaining injuries were diagnosed with ultrasound (6%) and magnetic resonance cholangiopancreatography (MRCP) (2%) and at the time of laparotomy or autopsy (12%). One hundred seventy-five patients (63%) underwent an operative intervention, most commonly a distal pancreatectomy (44%); however, there was great variability in operative procedure chosen even when considering grade of injury. CONCLUSION: Pancreatic injuries are associated with multiple other injuries and have significant morbidity and mortality. Their management demonstrates significant practice variation within a national trauma system. LEVEL OF EVIDENCE: Therapeutic/care management, level V; Prognostic and epidemiological, level IV.

Impact of interhospital transfer on patient outcomes in emergency general surgery.

BACKGROUND: Emergency general surgery patients are at an increased risk for morbidity and mortality compared to their elective surgery counterparts. The complex nature of emergency general surgery conditions can challenge community hospitals, which may lack appropriate systems and personnel. Outcomes related to transfer have not been well-established. We aimed to compare postoperative outcomes of patients who were transferred from another hospital to a center with dedicated acute care surgery services with patients admitted directly to the acute care surgery centers. METHODS: We performed a secondary analysis of a national, multicenter review of emergency general surgery patients undergoing complex emergency general surgery at 5 centers across Canada. The primary outcome was the development of any complication. The adjusted odds of postoperative complication was assessed using logistic regression, controlling for age, comorbidities, duration of stay before transfer, American Society of Anesthesiologists classification, and booking priority. RESULTS: A total of 1,846 patients were included in the study, and 176 (9.5%) were transferred. Of these 21% (n = 37) underwent an operative procedure, and 15% (n = 27) underwent an operation at the transferring center. Transferred patients were more likely to have at least 1 comorbidity (68% vs 57%; P = .004), were classified as greater urgency on arrival (<2 hours booking priority, 43% vs 17%; P < .001), had a greater American Society of Anesthesiologists classification (American Society of Anesthesiologists ≥3 = 81% vs 65%; P < .001), a greater duration of operation (119 vs 110 minutes; P = .004), and were more likely to undergo a second operation (28% vs 14%; P < .001) compared to patients directly admitted to an acute care surgery center. On univariate analysis, transferred patients had greater rates of complications (48% vs 31%; P < .001), mortality (14% vs 7%; P = .005), and admission to the intensive care unit (22% vs 12%; P < .001). Transfer status remained an independent predictor of complication (odds ratio 1.9 [95% confidence interval 1.3-2.7]; P < .001) and intensive care unit admission (odds ratio 1.9 [95% confidence interval 1.2-3.0]; P = .007), but not mortality (odds ratio 1.1 [95% confidence interval 0.6-1.9]; P = .79) on regression analysis. CONCLUSION: Complex emergency general surgery patients transferred to acute care surgery centers may have worse outcomes and greater use of resources compared to those admitted directly. This finding has clinically and financially important implications for the design and regionalization of acute care surgery services as well as resource allocation at acute care surgery centers.

Patterns of complex emergency general surgery in Canada.

BACKGROUND: Most of the literature on emergency general surgery (EGS) has investigated appendiceal and biliary disease; however, EGS surgeons manage many other complex conditions. This study aimed to describe the operative burden of these conditions throughout Canada. METHODS: This multicentre retrospective cohort study evaluated EGS patients at 7 centres across Canada in 2014. Adult patients (aged ≥ 18 yr) undergoing nonelective operative interventions for nonbiliary, nonappendiceal diseases were included. Data collected included information on patients' demographic characteristics, diagnosis, procedure details, complications and hospital length of stay. Logistic regression was used to identify predictors of morbidity and mortality. RESULTS: A total of 2595 patients were included, with a median age of 60 years (interquartile range 46-73 yr). The most common principal diagnoses were small bowel obstruction (16%), hernia (15%), malignancy (11%) and perianal disease (9%). The most commonly performed procedures were bowel resection (30%), hernia repair (15%), adhesiolysis (11%) and débridement of skin and soft tissue infections (10%). A total of 47% of cases were completed overnight (between 5 pm and 8 am). The overall inhospital mortality rate was 8%. Thirty-three percent of patients had a complication, with independent predictors including increasing age (p = 0.001), increasing American Society of Anesthesiologists score (p = 0.02) and transfer from another centre (p = 0.001). CONCLUSION: This study characterizes the epidemiology of nonbiliary, nonappendiceal EGS operative interventions across Canada. Canadian surgeons are performing a large volume of EGS, and conditions treated by EGS services are associated with a substantial risk of morbidity and mortality. Results of this study will be used to guide future research efforts and set benchmarks for quality improvement.

CONTEXTE: La plupart des études sur les services de chirurgie générale d'urgence (CGU) s'intéressent seulement aux atteintes de l'appendice et de la vésicule biliaire. Pourtant, les chirurgiens du domaine traitent beaucoup d'autres problèmes complexes. L'objectif de l'étude était de décrire le travail chirurgical associé à ces problèmes dans l'ensemble du Canada. MÉTHODES: Notre étude de cohorte rétrospective multicentrique inclut les patients adultes (≥ 18 ans) qui ont subi en 2014 une opération non planifiée pour une atteinte qui ne touchait ni l'appendice ni la vésicule biliaire dans 1 des 7 centres sélectionnés, répartis un peu partout au pays. Nous avons recueilli les données suivantes : renseignements de base des patients, diagnostic, détails de l'intervention, nature des complications et durée d'hospitalisation. Puis nous avons dégagé les facteurs prédictifs de morbidité et de mortalité en appliquant un modèle de régression logistique. RÉSULTATS: L'échantillon totalisait 2595 patients, pour un âge médian de 60 ans (écart interquartile 46­73 ans). Les diagnostics principaux les plus courants étaient l'occlusion de l'intestin grêle (16 %), la hernie (15 %), la tumeur maligne (11 %) et les lésions périanales (9 %). Les interventions les plus fréquentes étaient la résection de l'intestin (30 %), la réparation d'une hernie (15 %), le débridement (11 %) et le débridement de tissus mous ou cutanés infectés (10 %). L'opération a eu lieu le soir ou la nuit (entre 17 h et 8 h) dans 47 % des cas. Le taux global de mortalité à l'hôpital était de 8 %. Des complications sont survenues chez 33 % des patients, dont les facteurs prédictifs indépendants étaient l'âge avancé (p = 0,001), un score ASA (de l'American Society of Anesthesiologists) élevé (p = 0,02) et le transfert à partir d'un autre centre (p = 0,001). CONCLUSION: Cette étude dresse le profil épidémiologique des interventions effectuées par les services de CGU du Canada en présence d'atteintes autres que celles de l'appendice et de la vésicule biliaire. Les chirurgiens du pays font beaucoup d'interventions générales urgentes, pour traiter des affections associées à un risque élevé de morbidité et de mortalité. Les résultats de l'étude guideront les prochaines recherches et serviront de points de référence en matière d'amélioration de la qualité.

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.

A 30-day prospective audit of all inpatient complications following acute care surgery: How well do we really perform?

Background: Acute care surgery (ACS) and emergency general surgery (EGS) services must provide timely care and intervention for patients who have some of the most challenging needs. Patients treated by ACS services are often critically ill and have both substantial comorbidities and poor physiologic reserve. Despite the widespread implemention of ACS/EGS services across North America, the true postoperative morbidity rates remain largely unknown. Methods: In this prospective study, inpatients at 8 high-volume ACS/EGS centres in geographically diverse locations in Canada who underwent operative interventions were followed for 30 days or until they were discharged. Readmissions during the 30-day window were also captured. Preoperative, intraoperative and postoperative variables were tracked. Standard statistical methodology was employed. Results: A total of 601 ACS/EGS patients were followed for up to 30 inpatient or readmission days after their index emergent operation. Fifty-one percent of patients were female, and the median age was 51 years. They frequently had substantial medical comorbidities (42%) and morbid obesity (15%). The majority of procedures were minimally invasive (66% laparoscopic). Median length of stay was 3.3 days and the early readmission (< 30 d) rate was 6%. Six percent of patients were admitted to the critical care unit. The overall complication and mortality rates were 34% and 2%, respectively. Cholecystitis (31%), appendicitis (21%), bowel obstruction (18%), incarcerated hernia (12%), gastrointestinal hemorrhage (7%) and soft tissue infections (7%) were the most common diagnoses. The morbidity and mortality rates for open surgical procedures were 73% and 5%, respectively. Conclusion: Nontrauma ACS/EGS procedures are associated with a high postoperative morbidity rate. This study will serve as a prospective benchmark for postoperative complications among ACS/EGS patients and subsequent quality improvement across Canada.

Contexte: Les services de chirurgie dans les unités de soins actifs (CSA) et de chirurgie générale dans les services d'urgence (CGSU) doivent fournir rapidement des soins et des interventions à des patients dont les besoins sont parmi les plus complexes. En effet, les patients pris en charge par les services de CSA sont souvent gravement malades et présentent des comorbidités sur fond de faible réserve physiologique. Même si les services de CSA/CGSU se sont répandus en Amérique du Nord, les taux réels de morbidité postopératoire demeurent pour une bonne part inconnus. Méthodes: Dans cette étude prospective, on a suivi pendant 30 jours ou jusqu'à leur congé, les patients hospitalisés pour des interventions chirurgicales dans 8 centres de CSA/CGSU achalandés de divers endroits au Canada. On a également tenu compte des réadmissions dans les 30 jours. Les paramètres pré-, per- et postopératoires ont été enregistrés. Une méthodologie statistique standard a été appliquée. Résultats: En tout, 601 patients de CSA/CGSU ont ainsi été suivis pendant une durée allant jusqu'à 30 jours d'hospitalisation ou de réadmission après leur intervention urgente initiale. Cinquante et un pour cent étaient de sexe féminin et l'âge moyen était de 51 ans. Ces patients étaient nombreux à présenter des comorbidités de nature médicale substantielles (42 %) et une obésité morbide (15 %). La majorité des interventions ont été minimalement effractives (66 % laparoscopiques). La durée médiane des séjours a été de 3,3 jours et le taux de réadmission précoce (< 30 j) a été de 6 %. Six pour cent des patients ont été admis aux soins intensifs. Les taux globaux de complications et de mortalité ont été respectivement de 34 % et de 2 %. Cholécystite (31 %), appendicite (21 %), obstruction intestinale (18 %), hernie incarcérée (12 %), hémorragie digestive (7 %) et infections des tissus mous (7 %) comptent parmi les diagnostics les plus fréquents. Les taux de morbidité et de mortalité dans les cas de chirurgies ouvertes ont été respectivement de 73 % et 5 %. Conclusion: Les interventions de CSA/CGSU non liées à la traumatologie sont associées à un taux de morbidité postopératoire élevé. Cette étude fournira un ensemble de valeurs de références pour l'étude prospective des complications chez les patients pris en charge par les services de CSA/CGSU et l'amélioration subséquente des soins partout au Canada.

Mental toughness in surgeons: Is there room for improvement?

Background: Mental toughness is crucial to high-level performance in stressful situations. However, there is no formal evaluation or training in mental toughness in surgery. Our objective was to examine differences in mental toughness between staff and resident surgeons, and whether there is an interest in improving this attribute. Methods: We distributed a survey containing the Mental Toughness Index (domains of self-belief, attention regulation, emotion regulation, success mindset, context knowledge, buoyancy, optimism and adversity capacity) among general surgery residents and staff at 3 Canadian academic institutions. Responses were recorded on a 7-point Likert scale. Participants were also asked about techniques they used to help them perform under pressure and interest in further developing mental toughness. Results: Eighty-three of 193 surgeons participated: 56/105 (52.8%) residents and 27/87 (31.0%) staff. The average age was 29 (standard deviation 5) years and 42 (standard deviation 8) years, respectively. Residents scored significantly lower than staff in all mental toughness domains. Men scored significantly higher than women in attention regulation and emotion regulation. Age, staff experience and resident postgraduate year were not significantly associated with mental toughness scores. Twenty residents (36%) and 17 staff (63%) reported using specific techniques to deal with stressful situations; 49 (88%) and 15 (56%), respectively, were interested in further developing mental toughness. Conclusion: Staff surgeons scored significantly higher than residents in all mental toughness domains measured. Both groups expressed a desire to improve mental toughness. There are many techniques to improve mental toughness, and further research is needed to assess their effectiveness in surgical training.

Contexte: La force mentale est indispensable à un rendement de haut niveau en situation de stress. Par contre, il n'existe pas de méthode d'évaluation formelle ni de formation pour promouvoir la force mentale en chirurgie. Notre objectif était de comparer la force mentale des chirurgiens en poste à celle des résidents, et de vérifier si l'amélioration de cette compétence suscite l'intérêt. Méthodes: Nous avons distribué un questionnaire sur les divers domaines qui constituent l'indice de force mentale (confiance en soi, régulation de l'attention et des émotions, attitude gagnante, connaissances du contexte, dynamisme, optimisme et résistance à l'adversité) aux résidents et aux chirurgiens en poste en chirurgie générale dans 3 établissements universitaires canadiens. Les réponses étaient consignées sur une échelle de Likert en 7 points. Les participants ont aussi été interrogés sur les techniques qu'ils utilisent pour mieux composer avec la pression et sur leur intérêt pour l'acquisition d'une plus grande force mentale. Résultats: Quatre-vingt-trois chirurgiens sur 193 ont participé : 56/105 (52,8 %) résidents et 27/87 (31,0 %) chirurgiens en poste. L'âge moyen était de 29 ans (écarttype 5) et de 42 ans (écart-type 8), respectivement. Les résidents ont obtenu un score significativement moindre que les chirurgiens en poste pour tous les domaines constitutifs de la force mentale. Les hommes ont obtenu des scores significativement plus élevés que les femmes pour la régulation de l'attention et des émotions. L'âge, l'expérience des chirurgiens en poste et l'année de formation postdoctorale des résidents n'ont pas été significativement associés aux scores de force mentale. Vingt résidents (36 %) et 17 chirurgiens en poste (63 %) ont indiqué utiliser des techniques spécifiques pour affronter les situations stressantes; 49 (88 %) et 15 (56 %), respectivement, se sont montrés intéressés à acquérir davantage de force mentale. Conclusion: Les chirurgiens en poste ont obtenu des scores significativement plus élevés que les résidents pour tous les domaines de la force mentale mesurés. Les 2 groupes ont exprimé un intérêt pour l'amélioration de leur force mentale. Il existe plusieurs techniques à cet effet et il faudra approfondir la recherche pour en évaluer l'efficacité chez les chirurgiens en formation.

Evaluating Best Methods for Crisis Resource Management Education: Didactic Teaching or Noncontextual Active Learning.

INTRODUCTION: Health care training traditionally focuses on medical knowledge; however, this is not the only component of successful patient management. Nontechnical skills, such as crisis resource management (CRM), have significant impact on patient care. This study examines whether there is a difference in CRM skills taught by traditional lecture in comparison with low-fidelity simulation consisting of noncontextual learning through team problem-solving activities. METHODS: Two groups of multidisciplinary preclinical students were taught CRM through lecture or noncontextual active learning. Both groups were given a cardiopulmonary resuscitation simulation and clinical performance assessed by basic life support (BLS) checklist and CRM skills by Ottawa Global Rating Scale. The groups were reassessed at 4 months. A third group, who received no CRM education, served as a control group. RESULTS: The mean BLS scores after CRM education were 18.9 and 24.9 with mean Ottawa Global Rating Scale (GRS) scores of 22.4 and 29.1 in the didactic teaching and noncontextual groups, respectively. The difference between intervention groups was significant for BLS (P = 0.02) and Ottawa GRS (P = 0.03) score. At 4-month follow-up, there was no statistically significant difference in BLS (P = 1.0) or Ottawa GRS score (P = 0.55) between intervention groups. In comparison with the control group, there was a marginally significant difference in Ottawa GRS score (P = 0.06) at 4-month follow-up. CONCLUSIONS: Noncontextual active learning of CRM using low-fidelity simulation results in improved CRM performance in comparison with didactic teaching. The benefits of CRM education do not seem to be sustained after one education session, suggesting the need for continued education and practice of skills to improve retention.

A quality-improvement approach to effective trauma team activation

Background: Appropriate, timely trauma team activation (TTA) can directly affect outcomes for patients with trauma. A review of quality-performance indicators at our Canadian level 1 trauma centre showed a high level of undertriage, with TTA compliance rates less than 60% for major trauma. A quality-improvement project was undertaken, targeting a sustained goal of at least 90% TTA compliance based on Accreditation Canada guidelines. Methods: Quality-improvement action followed a well-defined process. Baseline data collection was performed, and, in keeping with the Donabedian approach, we brought together stakeholders to collectively review and understand the reasons behind poor TTA compliance; and root-cause analysis. This was followed by rapid change cycles that focused on structure and processes with ongoing audits to support and sustain change. Results: Trauma team activation compliance improved from 58.8% to more than 90% over 2 years. Quality indicators showed a statistically significant reduction in the time to computed tomography scanner, time in the acute care region of the emergency department and total time in the emergency department, with improved TTA compliance. Conclusion: Compliance with TTA protocols improved to more than 90% over a 2-year period, which shows the benefit of having a clearly outlined qualityimprovement process. This well-defined quality-improvement method provides a framework for use by other institutions that seek to improve their processes of trauma care, including activation rates.

Contexte: Le déploiement rapide et approprié de l'équipe de traumatologie (DÉT) peut avoir une influence directe sur les résultats chez les polytraumatisés. Une revue des indicateurs de qualité/performance dans notre centre de traumatologie canadien de niveau 1 a révélé une lacune importante au plan du triage, et des taux de conformité aux protocoles de DÉT atteignant moins de 60 % pour les traumatismes majeurs. Un projet d'amélioration de la qualité a donc été entrepris avec pour objectif une conformité soutenue d'au moins 90 % aux protocoles de DÉT selon les lignes directrices d'Agrément Canada. Méthodes: Les mesures d'amélioration de la qualité ont suivi un processus bien défini. Une collecte des données de référence a été effectuée, et conformément au modèle de Donabedian, nous avons réuni les différentes parties intéressées pour revoir et comprendre ensemble les raisons de la piètre conformité aux protocoles de DÉT et procéder à leur analyse en profondeur. On a ensuite appliqué des cycles de changements rapides axés sur la structure et les procédés, accompagnés de vérifications en continu pour les appuyer et les maintenir. Résultats: La conformité aux protocoles de déploiement de l'équipe de traumatologie s'est améliorée, passant de 58,8 % à plus de 90 % en l'espace de 2 ans. Les indicateurs de qualité ont montré des réductions statistiquement significatives du délai prétomographie, du temps passé dans la section de soins aigus du service des urgences et du temps total passé aux urgences, de même qu'une meilleure conformité aux protocoles de DÉT. Conclusion: La conformité aux protocoles de DÉT s'est améliorée pour dépasser les 90 % en l'espace de 2 ans, ce qui montre l'efficacité d'un processus d'amélioration de la qualité clairement défini. Cette méthode d'amélioration de la qualité bien définie fournit un cadre que d'autres établissements peuvent appliquer s'ils cherchent à améliorer leurs protocoles de traumatologie, y compris la vitesse de leur déploiement.

Small Bowel Obstruction Secondary to Entrapment in a Minimally Displaced Acetabular Fracture: A Case Report.

CASE: We present a unique case of bowel entrapment within a minimally displaced acetabular fracture. Our patient was injured after a fall from height. He was able to walk with minimal pain, and presented to hospital the following day for symptoms consistent with bowel obstruction. Imaging demonstrated a transition point at the fracture site. He was taken for emergency surgical decompression, bowel repair, and irrigation of his hip. CONCLUSIONS: Bowel entrapment within a pelvic fracture is rare. Our case illustrates the importance of maintaining a high level of suspicion, despite fracture displacement, to allow early diagnosis and appropriate management.

Rectus sheath single-injection blocks: a study to quantify local anaesthetic absorption using serial ultrasound measurements and lidocaine serum concentrations.

OBJECTIVES: Rectus sheath blocks are an established option for analgesia following abdominal surgery, but pharmacokinetic data are limited. This study sought to characterise the absorption of lidocaine injectate and the pharmacokinetics of lidocaine after rectus sheath injection. METHODS: Bilateral rectus sheath single-injection blocks were given to 10 patients undergoing general or urological surgery. Afterwards, serial lidocaine serum levels and ultrasound measurements of the rectus sheath injectate reservoir were collected. KEY FINDINGS: Injectate within the rectus sheath was visible with ultrasound up to 12 h after injection. However, the rate of drug absorption exceeded that of injectate disappearance. Peak serum concentration occurred within 30 min with average peak concentrations of 1.65 µg/ml. Lidocaine clearance was lower than reported in young healthy subjects. The body mass index positively correlated with lidocaine terminal phase half-life, and clearance negatively correlated with age. CONCLUSIONS: The study provides the first data describing lidocaine pharmacokinetics after rectus sheath injection. Peak serum concentrations transiently achieved systemic levels associated with pain relief after a single bolus injection. The data from this study could be used to develop a regime using single shot rectus sheath blockade with a bolus of lidocaine followed by infusion using bilateral rectus sheath catheters.