Amanda McFarlan Bio

Jo-Ann Hnatiuk Bio

INTRODUCTION

Welcome to the ITNC Trauma Program online resource. This resource is intended to provide new and current Canadian Trauma Program staff with information and guidance in regard to building a robust Trauma System and Program within their region and institution. This online resource is a guide and reference only and should be used in conjunction with other national documents and tools provided by TAC and other trauma program resources, along with your own organization mandates.

Canadian Trauma Systems are described fully in the TAC accreditation guidelines document online. Click Trauma Distinction to access online.

In Canada, trauma centres range from level I to V and all fit within a comprehensive trauma system. Each trauma system is unique, depending on your province/territory/region, the populations served and organizational and/or ministry mandates and direction.

I.  TAC ACCREDITATION

The Trauma Association of Canada and Accreditation Canada have completed the development of a Trauma Distinction program.

II.  TRAUMA SYSTEMS

1.  Provincial/Regional

Provincial and Regional Trauma Systems in Canada are defined in the TAC Accreditation Guidelines as: “A fully comprehensive and inclusive trauma system is a preplanned, organized, and coordinated injury control effort in a defined geographic area (province or region), which:

Has an identifiable lead agency.

Is publicly administered, funded and accountable.

Engages in comprehensive injury surveillance, reporting and prevention programs.

Delivers the full spectrum of trauma care from the time of injury to recovery including:

• Immediate access to emergency medical services
• Rapid transport to appropriate level of care
• Acute services including resuscitation, surgery, critical care and specialty services
• Rehabilitation and reintegration into the community and workforce
• Engages in research, training and performance improvement
• Establishes linkages with an all-hazards emergency preparedness program.”

For a formal overview of trauma systems in Canada, click here and scroll to the Trauma Systems section.  List of Canadian Trauma Programs Contact Info by Province 2017.xls by province with contact information

2014 edition American College of Surgeons Resource for the Optimal Care Trauma Patient 2014.pdf

2.  Roles

Within a trauma system, there are many different roles and responsibilities of the varied levels of the designated trauma centres.  Trauma centre designation ranges from Level I through V, each playing an essential role within the larger system.  Each one of these sites, and roles within those sites, will be dependent on the resources available.

Each Centre will have a number of Trauma Program roles or supporting roles including, but not limited to:

 

3.  Committees

The success of any trauma program, regardless of designation level, is dependent on strong working relationships with key internal and external stakeholders along the trauma continuum. Each organization/department has a unique and distinct culture that must be respected and upheld within the development of any process, policy or guideline. Recognizing that there is no one ideal framework that will guarantee success in all organizations, developing strong collaborative relationships with all stakeholders should facilitate compliance of the elements of any process, policy or protocol.

Tips for success include:

• Establish quality working groups along the trauma continuum
• Include all stakeholders from multidisciplinary areas involved in the care of the trauma patient
• Integrate and link with the organizational quality and safety committee and initiatives
• Guarantee that all committee work aligns and is linked with the strategic direction of the organization
• To maintain accountability of all committee work, establish an effective reporting structure to the leadership of the program and organization

III.  PERFORMANCE IMPROVEMENT/PATIENT SAFETY (PIPS)

1.  Quality Assurance (QA)

Quality assurance has been brought to the forefront in many health agencies. Having an accountable quality assurance process is essential, as trauma quality involves multiple disciplines and departments. This process as well as specific performance indicators will vary depending on the level centre.

Resources for optimal care of the injured patientsis a publication of the American College of Surgeons, Committee on Trauma, and contains a section on PIPS.

Below is a spreadsheet listing various performance improvement projects that trauma program managers, coordinators, nurses, IP managers etc. are involved in at their centres (or region). This document includes a very brief description of the stage the project is at and a contact name/email for each project.  This spreadsheet is an ongoing work in progress based on submissions received during a number of ‘call outs’ for submissions; if you are not on the list and want to add or correct your site contact information and/or project details please email Amanda McFarlan at mcfarlana@smh.ca

• ITNC PI resource file December 12 2013.xlsx

2.  Registries

A trauma registry is a disease-specific data collection composed of a file of uniform data elements that describe the injury event, demographics, prehospital information, diagnosis, care, outcomes, and treatment of the injured patient.

A Trauma Registry is a vital component of a trauma system. A well designed Trauma Registry containing consistent and accurate data can support all functions of a Trauma Program from basic reporting of trauma patient demographics and trends over time to informing injury prevention specialists of target populations, supporting trauma patient performance improvement and patient safety initiatives, trauma research, identifying trauma patient resource requirements and informing policy and trauma program planning. For more information about the development and the Trauma Registry as a component of a trauma system see the Injury Surveillance and Trauma Registry Information Management Orientation Manual.

Most provinces have provincial registries. In addition, data is available through your facility’s Discharge Abstract Database (DAD) as well as CIHI.

IV.  CONTINUUM OF CARE

1.  Injury Prevention

Injury prevention may be provided by multiple agencies or government branches.  Some institutions will participate in primary injury prevention initiatives, while others link with the agencies providing these initiatives.  A strong link between a trauma system and injury prevention specialists is encouraged.
Helpful links:

Exciting new resource for injury prevention! Check out the Canadian Injury Prevention Resource

All Ages

• Parachute (Safe Kids Canada, Smartrisk, ThinkFirst, Safe Committees
• BC Injury Research and Prevention Unit
• NB Trauma Program
• Ontario Injury Resource Centre
• Injury Prevention Centre (Alberta – formerly ACICR)

Children/Youth 

• Canadian Association Sports Medicine
• Child Safety Link
• Million Messages
• P.A.R.T.Y.
• Transport Canada

Videos

• No Magic Goat (Alcohol and Injury) 
• No Seatbelt No Excuse
• Pedestrian Cell Phone Distraction 
• Playground Safety 
• Walk Safe video

Alcohol

• Alcohol Screening and Brief Intevnetion COT.pdf
• Canadian Centre on Substance Abuse 

Concussions

• General Information
• Concussion Online Toolkit
• Concussion e-learning 
• Concussion 101 video

Seniors

• Canadian Fall Prevention Collaborative 
• CDC Older Adult Falls
• Finding Balance Alberta 
• Falls Prevention in Older Adults

2.  Prehospital and Communication

A Trauma System must develop strong links with prehospital care providers. Ongoing communication between prehospital and acute care centres may occur through regularly scheduled meetings. The development of a quality assurance process between centres and the prehospital care providers is an important aspect of quality care.

Resources – Field Trauma Triage Guidelines are available online by looking at regional or provincial sites depending on the province.

3.  Rehabilitation
Links with rehab

4.  Emergency Preparedness

5. Trauma Education and Outreach

Simulator trauma training is now a standard.

The following are trauma focused education:

The Trauma Nurse Core Course(TNCC) 
TNCC Provider Course is intended for nurses working in any setting and who come into contact with patients who have suffered a traumatic injury. The Registered Nurse will learn a systematic approach to assessing, stabilizing and treating the trauma patient, through lectures and hands on stations. This internationally recognized course concludes with a testing session that consists of a multiple choice theory examination and tested skill station. This course is an excellent review for the experienced nurse and a sound framework for a nurse new to the Trauma or Emergency setting. The course is licensed and maintained in Canada by the National Emergency Nurses Association (NENA).

To find courses in your area go toENA or email courses@nena.ca

Advanced Trauma Care for Nurses (ATCN) 

ACTN is an advanced course designed for the registered nurse interested in increasing his/her knowledge in management of the multiple trauma patient. The ATCN course is taught concurrently with the American College of Surgeons (ACS) Advanced Trauma Life Support® (ATLS).  The ATCN program is currently being offered in some sites in Ontario. There is a 6-month planning process for all inaugural courses.

Rural Trauma Team Development Course (RTTDC)

RTTDC was developed by the American College of Surgeons. The one-day course teaches health-care professionals in small rural hospitals how to employ a team approach in the primary assessment, resuscitation and transfer of a trauma patient to the appropriate trauma centre. The course emphasizes that a team of three can effectively manage this procedure – a physician, a nurse and one other (likely another nurse or allied health professional). The course includes discussion about communication techniques and performance improvement. The afternoon is dedicated to hands on simulation cases. The course is available in English and French.

Advance Trauma Life Support (ATLS)

The American College of Surgeons (ACS) and its Committee on Trauma (COT) have developed the Advanced Trauma Life Support (ATLS) program for doctors. The Advanced Trauma Life Support course teaches a systematic, concise approach to the early care of the trauma patient. This course is vital to guiding care for the injured patient in emergency department trauma rooms. ATLS course training provides a common language that can save lives in critical situations.

The ATLS program provides participants with a safe, reliable method for immediate management of the injured patient and the basic knowledge necessary to:

For doctors who infrequently treat trauma, the ATLS course provides an easy to remember method for evaluating and treating the victim of a traumatic event. For doctors who treat traumatic disease on a frequent basis, the ATLS course provides a scaffold for evaluation, treatment, education, and quality assurance. In short, ATLS is a measurable, reproducible, and comprehensive system of trauma care.

The ATLS course may be audited by non-physician members of the trauma team.

Definitive Surgical Trauma Course (DSTC)
“This postgraduate surgical course for 20 participants assumes competence with assessment and resuscitative measures, which have become standardized in North America through The American College of Surgeons ATLS® Course. It draws on the specialist surgical training of all course participants and reviews, strengthens and organizes the performance of established and new procedures specially required in trauma surgery.”

Advanced Trauma Operative Management (ATOM)

Online Resources

Trauma guidelines –www.guidelinesforme.com

Trauma Podcast – EMCrit 

6.  Research
CRASH-2: Tranexamic Acid and Trauma Patients

Trauma Clinical Practice Guidelines 

Canadian C-spine Rules 

Canadian Head CT Rules

Field Trauma Triage Guidelines 2011 

V.  SPECIAL POPULATIONS(PEDIATRICS/BARIATRICS/GERIATRICS/PREGNANT, ETC)

The trauma nurse needs to realize that not all populations can be treated equally. Pregnant, Pediatric and Geriatric trauma patients need special considerations for assessment, planning, intervention and evaluation of the trauma process. Each population responds uniquely to traumatic injury and it is important to anticipate these differences from the typical response.

Pediatrics:

Injury is the number one cause of death and disability in pediatric patients up to 14 yrs of age. The greatest pitfall related to pediatric trauma is the failure to have prevented it in the first place. There are a number of differences between a typical young adult and a pediatric patient. Knowledge of the pediatric anatomy and physiological responses is necessary to have the best outcome for the pediatric trauma patient.

Airway and Breathing:

• Airway Obstruction is more likely due to:
• • Infants are obligatory  nose breathers
  • Airways are more susceptible to edema
  • More anterior larynx – aspiration more likely
  • Tongue is relatively larger
• Airway is shorter – unrecognized extubation is common
• Respiratory rates are faster:
• • Increased metabolic demand
  • Increased oxygen consumption
  • Significantly lower oxygen stores
  • More need to supply supplemental oxygen

Spinal Immobilization:

• Elevation of the entire trunk may be necessary to help compensate for the large occiput when laying flat in full spinal immobilization
• Spinal ligaments are more lax – leading to increased risk of ligamental injuries or Spinal Cord Injuries With Out Radiological Abnormalities (SCIWORA)

Circulation:

• Normal heart rate and blood pressure vary with age – have references near
• • Heart rate increases for many factors – anxiety, pain, agitation, volume loss
  • Heart rate increases instead of stroke volume to increase cardiac output
  • Blood pressure is maintained longer by increased peripheral vascular resistance until approximately 25% blood loss
• Blood volume is dependent on size
• • Circulating volume in children: approximately 80mL/kg
• Central capillary refill is the best indicator for perfusion
• Crystalloid fluid resuscitation bolus is 20mL/kg
• Blood replacement is 10mL/kg
• Subgaleal blood loss may be significant in infants

Disability:

• Pediatric GCS reference is necessary for accurate scoring

Exposure:

• Temperature regulation is less effective – keep kids warm

Other Anatomic and Physiological Characteristics:

• Significantly lower glycogen stores
• Children gulp air when they cry or if being assisted with BVM ventilation – gastric deflation may be necessary sooner
• Skull bones are thinner
• Diffuse axonal injury is more common
• Abdominal muscles are thinner making the internal organs more susceptible to injury
• Extremity bones are more pliable – need a great force to fracture
• Medication dosages are calculated according to weight
• Broselow tape reference is encouraged

Check outTREKK – Translating Emergency Knowledge of Kids. TREKK is a growing network of researchers, clinicians, national organizations and health consumers who share the same goal – to improve emergency care for children across Canada.

Geriatrics:

The traumatically injured older adult represents a subset of patients that present additional challenges to the health care team. (Fallon et al 2006). Delays in recognizing the special needs of older adult trauma patients can result in sub‐optimal care (Scalea et al 1990), an increase in resource utilization and significant mortality (Demetriades et al 2001).

Canada’s population is aging quickly and this rapid ageing is projected to last until 2031, when seniors would account for between 23 % and 25 % of the total population. This would be almost double the 2006 proportion of 13.7 % (Statistics Canada Daily 2006). When older adults sustain injury they have an increased mortality risk despite lower injury severity related to a narrow physiologic tolerance and reserve (McMahon et al 2000 Miltzman1996). In order to improve outcomes for this group additional service and resource provision throughout the patient care journey is required (Fallon et al 2006).

Optimal care of the elderly trauma patient requires making a commitment to providing appropriate resources and expertise through to ultimately improve outcomes. In addition to standard trauma management, care of the elderly requires an appreciation of potentially decreased physical reserves, presence of co‐morbidities and complication risks. The development of care plans and protocols should be designed to prevent or mitigate age‐specific complications related to co‐morbidities or new‐onset of conditions and assist in discharge planning (Fallon et al 2006).

Consider the following factors in the context of elderly trauma patients:

Pre-hospital care should be the same as any other adult trauma.  The only consideration should be recognizing that pregnancy greater than 20 weeks gestation should be criteria alone to transfer to nearest trauma receiving facility.  Pre-notification should include ‘pregnant greater than 20 weeks’ to ensure Obstetrics are consulted as part of the initial trauma team activation upon arrival to the facility.

Initial trauma management for less than 20 weeks gestation should focus on resuscitation and stabilization of the patient (Mother).  For greater than 20 weeks gestation, fetal well-being and risk should be considered and interventions directed by local protocols (ie. Emergency C-section).

Primary survey to include auscultation of fetal heart rate and patient should be positioned hip tilt to left side (unless suspected lower spine, pelvic or hip fracture) or clam shell should be tilted to the right with patient well secured.  Secondary survey with patients greater than 20 weeks gestation should include pelvic and uterine exam and possible pelvic/obstetrical ultrasound.  Continual patient monitoring should include fetal assessment, either by intermittent auscultation of Fetal Heart Rate or preferably with continuous fetal monitoring equipment. Assess for contractions and signs of preterm labour.

Once initial trauma assessments have been completed, if patient is cleared by trauma physician, consider admission to Obstetrics for monitoring of fetal well-being.

The ITNC Forum is available for specific special population discussions.