Toward an all-inclusive trauma system in Central South Ontario: development of the Trauma-System Performance Improvement and Knowledge Exchange (T-SPIKE) project.

Background: There is currently no integrated data system to capture the true burden of injury and its management within Ontario's regional trauma networks (RTNs), largely owing to difficulties in identifying these patients across the multiple health care provider records. Our project represents an iterative effort to create the ability to chart the course of care for all injured patients within the Central South RTN. Methods: Through broad stakeholder engagement of major health care provider organizations within the Central South RTN, we obtained research ethics board approval and established data-sharing agreements with multiple agencies. We tested identification of trauma cases from Jan. 1 to Dec. 31, 2017, and methods to link patient records between the various echelons of care to identify barriers to linkage and opportunities for administrative solutions. Results: During 2017, potential trauma cases were identified within ground paramedic services (23 107 records), air medical transport services (196 records), referring hospitals (7194 records) and the lead trauma hospital trauma registry (1134 records). Linkage rates for medical records between services ranged from 49% to 92%. Conclusion: We successfully conceptualized and provided a preliminary demonstration of an initiative to collect, collate and accurately link primary data from acute trauma care providers for certain patients injured within the Central South RTN. Administration-level changes to the capture and management of trauma data represent the greatest opportunity for improvement.

Contexte: On ne dispose actuellement d'aucun système intégré de gestion des données pour évaluer le fardeau réel des traumatismes et de leur gestion dans les réseaux régionaux de traumatologie (RRT) en Ontario, en bonne partie en raison de la difficulté d'identifier les cas parmi la multiplicité des dossiers d'intervenants médicaux. Notre projet représente un effort itératif pour créer la capacité de cartographier le parcours de soin de tous les polytraumatisés du RRT de la région Centre-Sud. Méthodes: Grâce à l'engagement général des intervenants des grandes organisations de santé du RRT de la région Centre-Sud, nous avons obtenu l'approbation d'un comité d'éthique de la recherche et conclu des accords de partage des données avec plusieurs agences. Nous avons testé l'identification des cas de traumatologie du 1er janvier au 31 décembre 2017 et les méthodes de liaison des dossiers de patients entre les divers échelons de soin pour identifier les obstacles à la liaison et leurs solutions administratives possibles. Résultats: Au cours de 2017, les cas de traumatologie potentiels ont été identifiés auprès des services ambulanciers terrestres (23 107 dossiers), des services de transport médical aérien (196 dossiers), des hôpitaux référents (7194 dossiers) et du registre hospitalier principal de traumatologie (1134 dossiers). Les taux de liaison entre les différents services pour les dossiers médicaux variaient de 49 % à 92 %. Conclusion: Nous avons conceptualisé et présenté avec succès la démonstration préliminaire d'un projet visant à recueillir, colliger et relier avec justesse les données primaires des intervenants en traumatologie aiguë pour certains patients blessés du RRT du Centre-Sud. Des changements administratifs centrés sur la saisie et la gestion des données de traumatologie représentent la meilleure voie vers une amélioration.

IV access in bleeding trauma patients: a performance review.

BACKGROUND: Exsanguinating haemorrhage is a leading cause of death in severely injured trauma patients. Management includes achieving haemostasis, replacing lost intravascular volume with fluids and blood, and treating coagulopathy. The provision of fluids and blood products is contingent on obtaining adequate vascular access to the patient's venous system. We sought to examine the nature and timing of achieving adequate intravenous (IV) access in trauma patients requiring uncrossmatched blood in the trauma bay. METHODS: We performed a retrospective chart review of all patients admitted to our trauma centre from 2005 to 2009 who were transfused uncrossmatched blood in the trauma bay. We examined the impact of IV access on prehospital times and time to first PRBC transfusion. RESULTS: Of 208 study patients, 168 (81%) received prehospital IV access, and the on-scene time for these patients was 5 min longer (16.1 vs 11.4, p<0.01). Time to achieving adequate IV access in those without any prehospital IVs occurred on average 21 min (6.6-30.5) after arrival to the trauma bay. A central venous catheter was placed in 92 (44%) of patients. Time to first blood transfusion correlated most strongly with time to achieving central venous access (Pearson correlation coefficient 0.94, p<0.001) as opposed to time to achieving adequate peripheral IV access (Pearson correlation coefficient 0.19, p=0.12). CONCLUSIONS: We found that most bleeding patients received a prehospital IV; however, we also found that obtaining prehospital IVs was associated with longer EMS on-scene times and longer prehospital times. Interestingly, we found that obtaining a prehospital IV was not associated with more rapid initiation of blood product transfusion. Obtaining optimal IV access and subsequent blood transfusion in severely injured patients continues to present a challenge.

Societal costs of inappropriate emergency department thoracotomy.

BACKGROUND: Emergency department (ED) thoracotomy can be lifesaving. It can also lead to resource waste and exposure to blood-borne infections. We investigated the frequency with which ED thoracotomy was performed for inappropriate indications and the resulting societal costs. STUDY DESIGN: This retrospective cohort study examined all trauma patients admitted directly from the scene of injury from 1992 to 2009 who underwent ED thoracotomy. The main outcomes included inappropriate ED thoracotomy. Secondary outcomes included resource use and societal costs for performing ED thoracotomy for improper indications. Specifically, we analyzed for operating room use, blood transfusions, ICU and hospital stay, needlestick injuries, survivor rate, and neurological outcomes in this group. RESULTS: One hundred and twenty-three patients underwent ED thoracotomy during the study period. Of those, 63 (51%) were considered inappropriate. In this group, we observed no survivors, none became organ donors, 3 cases of needlestick injuries to health care providers occurred, and 335 U of blood products were used in their care. Also, 4 patients of 63 survived to the operating room and required a total of 6 separate operating room visits. Three of these patients had an ICU stay of 1 day and 1 died on day 5. CONCLUSIONS: ED thoracotomy should be reserved for potentially salvageable patients, but discouraged for other indications. From the societal point of view, inappropriate use of the procedure resulted in substantial costs and waste of resources, exposure of health care providers to possible blood-borne infections, and offered no survival benefit.

A universal global rating scale for the evaluation of technical skills in the operating room.

BACKGROUND: The ideal assessment of technical skills should be defensible and practical. The purpose of this study was to evaluate the utility of a Global Rating Scale (GRS) Assessment tool of resident operating room performance. METHODS: Residents were assessed in the operating room on multiple occasions during a 6-month study period using a 9-item GRS. Data were analyzed to assess scale reliability and sensitivity to year of training. Feasibility was evaluated with a post-study questionnaire. RESULTS: Seven residents had a total of 32 procedures assessed. One-way analysis of variance (ANOVA) showed that scores increased with year of training (P = .009). Reliability was excellent. (Cronbach's alpha .91). The post-study survey identified feedback and faculty interaction as strengths of this tool, but time constraint was a barrier. CONCLUSIONS: The GRS tool is a valid and reliable method that has the potential to be a practical, useful assessment tool of resident operating room performance.