TRAUMA DISTINCTION Protocols Performance Indicators Excellence and Innovation Program Overview Acute Trauma Services Trauma Distinction recognizes trauma systems that demonstrate clinical excellence and an outstanding commitment to leadership in trauma care. It offers rigorous and highly specialized standards of excellence, in-depth performance indicators and protocols, and an on-site visit by expert evaluators with extensive practical experience in trauma. The program includes an on-site visit every two years. Key components of the program include: : Distinction standards are based on the latest research and evidence related to excellence in trauma care. The trauma standards closely align with the (TAC) Trauma System Accreditation Guidelines. Protocols: Distinction includes the use of evidence-based protocols to promote a consistent approach to care and increase effectiveness and efficiency. Indicators: A key component of the Distinction program is the requirement to submit data on a regular basis and meet performance thresholds on a core set of performance indicators. Excellence and Innovation: Distinction clients must demonstrate implementation of a project or initiative that aligns with best practice guidelines, utilizes the latest knowledge, and integrates evidence to enhance the quality of care.
Overview The Trauma Distinction program includes three sets of standards for trauma services developed in collaboration with the Trauma Association of Canada (TAC): 1-Trauma System, 2-Acute Trauma Services and 3-Rehabilitation System standards. The Acute Trauma Services standards cover the essential components that I to V trauma centers should have in place to ensure the successful functioning of the trauma system as a whole. The acute phase covers the assessment and management of trauma patients from the incident scene until the patient is medically stable and able to begin rehabilitation or proceed to an alternate level of care. Accreditation Canada Acute Trauma Services standards consist of the following sections: Planning and Designing the Trauma Centre Providing Coordinated Trauma Care Helping Patients and Families Cope with Trauma Evaluating the Quality of the Trauma Centre Page -2- Pilot Version (July 5 2013)
Structure A set of standards is divided into sections that address different aspects of delivering safe and quality services. Each section consists of related standards, criteria, and guidelines. 1.0 The standard. A goal statement under which associated criteria are grouped. 1.1 The criterion. A measurable element that defines what is required to achieve the standard. Evaluators rate each criterion during the on-site survey. Criterion Types: High Priority: Foundational requirements for delivering safe and quality services. Protocol: Essential protocols that an organization must have in place to promote a consistent approach to care and increase effectiveness and efficiency. Indicator: Criteria linked to the requirement to submit data on a regular basis and meet performance thresholds on a core set of performance indicators. Excellence and Innovation: Criteria linked to the requirement of having a project or initiative that aligns with best practice guidelines, utilizes the latest knowledge, and integrates evidence to enhance the quality of care. Guidelines: Some criteria include guidelines that provide additional information and/or suggestions on how to comply with the criterion. Page -3- Pilot Version (July 5 2013)
Glossary Lead Agency: A designated agency with the authority to ensure appropriate development, management and ongoing quality improvement of the trauma system. The lead agency defines the number and level of trauma centres required within its jurisdiction to ensure quality care for trauma patients. Depending on jurisdiction, the lead agency might be the regional health authority or provincial health authority. Some of the components of the trauma system may not be under its direct jurisdiction such as Emergency Medical Services (EMS). Injury: Injuries are normally classified as intentional or unintentional. Intentional injuries are self-inflicted or inflicted by another person such as suicide/self-harm, violence and abuse. Examples of unintentional injuries include vehicle collisions, falls, drowning and unintentional poisoning. Medical Leader: Medical leaders are normally certified by the Royal College of Physicians and Surgeons of Canada and their respective provincial college of physicians and surgeons, or by the Collège des médecins du Québec. Certification requirements will vary per jurisdiction. Partner: An organization or person who works with another organization to address a specific issue by sharing information and/or resources. Protocols: Protocols ensure that services are delivered in a consistent manner based on best practices in the field. They can be in the form of guidelines, algorithms or checklists. Resources: Refers to human, financial and/or informational resources needed to support a project or initiative. Telehealth: A method for delivering services via telecommunication technologies. Telehealth can be used to deliver health-related services, maintain communication, or provide consultation or education. Examples include telephone and video communication links between two or more settings. Timely/Regularly: The trauma system defines what "timely" and "regularly" mean and adheres to that schedule. Page -4- Pilot Version (July 5 2013)
Trauma Centre: A centre designated and supported by the appropriate health authority to provide services to injured patients. TAC has defined seven levels of care for trauma services ranging from I to V, and Pediatric I and II. hospitals across the different levels of care are critical to the successful functioning of the trauma system as a whole. s I and II refer to hospitals with a primary role in providing care for major trauma. s III, IV and V provide essential trauma care until the patient can be transferred to a I or II trauma center as appropriate. Trauma System: A pre-planned, organized, and coordinated injury control effort in a defined geographic area (e.g. province or region) that is led by a governmental agency. The configuration of the trauma system will depend on the size of the population and jurisdiction. For example, regional trauma systems are normally based on a population of 1 to 2 million people and consolidate the major trauma cases into one or two major trauma centres (i.e. I or II) while distributing the larger volume of less severely injured patients across many hospitals (i.e. III, IV or V). Larger provinces may need several regional trauma systems coordinated by a common provincial trauma plan. Page -5- Pilot Version (July 5 2013)
Planning and Designing the Trauma Centre Section VI Criteria for Trauma Centres 1.0 The trauma centre is formally integrated within the trauma system. A. Trauma System Integration 1.1 The trauma centre has clear roles and responsibilities within the trauma Defined roles within the system (A) system. Criterion Type: High Guidelines: The roles and responsibilities of the trauma centre will vary depending on the level of care designated by the lead agency Higher levels are equipped to manage major trauma cases while lower levels provide initial resuscitation before transferring patients to a major trauma centre. Lower levels also complement major trauma centres by managing secondary (non-major) trauma cases. Higher level trauma centres play a leadership role within the trauma system by working closely with pre-hospital, inter-facility and rehabilitation services to develop and evaluate the trauma system as well as the emergency preparedness plan. Leadership role within the system (administrative, planning, clinical programs) (A) 1.2 The trauma centre participates in the lead agency responsible for the development, management and ongoing quality improvement of the trauma system. Guidelines: Higher level trauma centres play a leadership role within the trauma system by working closely with pre-hospital, inter-facility and rehabilitation services to develop and evaluate the trauma system as well as the emergency preparedness plan. I, II, P-I, Leadership role within the system (administrative, planning, clinical programs) (A) Page -6- Pilot Version (July 5 2013)
1.3 The trauma centre has a representative on the trauma system s interdisciplinary advisory committee to provide guidance throughout the development, management and ongoing quality improvement of the trauma system. Guidelines: The roles and responsibilities of the advisory committee include surveillance, supporting educational and research activities, coordinating pre-hospital services, promoting injury prevention programs, participating in the emergency preparedness planning and developing the annual report. 1.4 The trauma centre participates in the trauma system s Performance Improvement and Patient Safety (PIPS) program to evaluate how trauma services are delivered. Guidelines: The PIPS program is an organized and comprehensive review of trauma care and patient outcomes. Evaluation results can be used to improve the quality of trauma care to the population served, to drive research, and contribute to system integration or surveillance initiatives. Quality improvement is a collaborative process that involves all trauma centres within the trauma system. Trauma centres contribute to the trauma system s PIPS program by identifying strengths and areas for improvement, and following-up on evaluation results. Participation within Trauma System Advisory Body (A) Participation in System PIPS (A) Page -7- Pilot Version (July 5 2013)
1.5 The trauma centre provides trauma outreach education programs as identified by the trauma system. Guidelines: Higher level trauma centres provide educational and clinical support to other trauma centres within the trauma system. Outreach education programs are interdisciplinary and offered to physicians, nurses, allied health professionals and other service providers as required. Examples include Advanced Life Support Course (ATLS) for physicians, Trauma Nurse Core Course (TNCC), Advanced Trauma Care for Nurses (ATCN) and either Advanced Trauma Operative Management (ATOM) or Definitive Surgical Trauma Care (DSTC) for community surgeons. 1.6 The trauma centre has an emergency preparedness plan for mass casualty incidents that is integrated within the trauma system s overall plan. Guidelines: trauma centres play a critical role in planning a coordinated and efficient response to mass casualty incidents and disasters. The plan addresses triage of major trauma patients to higher level trauma centres, and less severely injured patients to lower level trauma centres. I, II, P-I, Trauma Outreach Education (A) Emergency Preparedness (A) Page -8- Pilot Version (July 5 2013)
2.0 The trauma centre has a leadership team with clear roles and responsibilities for trauma services. 2.1 The trauma centre has an administrative structure in place with clear reporting relationships and lines of accountability. Criterion Type: High Guidelines: The administrative structure of the trauma centre includes medical and administrative leaders, and an interdisciplinary advisory committee. Reporting relationships and lines of accountability are described in an organizational chart. The administrative structure reports to the trauma system s lead agency. 2.2 The medical leader is responsible for the clinical components of trauma services. Guidelines: The clinical components include medical direction, program support and ongoing quality improvement activities. Pediatric subspecialty training is required for P-I and. 2.3 The administrative leader works with the medical leader to set goals and objectives for trauma services. Guidelines: A co-leadership role is shared between the administrative and medical leaders. The goals and objectives describe how the trauma centre will achieve high quality trauma care. This includes identifying partnerships and linking the trauma centre s goals and objectives to the trauma system s strategic direction. B. Hospital Commitment and C. Trauma Leadership Roles Medical Director responsible for Clinical Trauma Services (C) Trauma as designated priority program/service (B) Trauma program manager/director who has the responsibility and authority for coordination and management of trauma care in collaboration with the Trauma Director (C) Co leadership of Trauma Program/Administration (C) Page -9- Pilot Version (July 5 2013)
2.4 The administrative leader has access to administrative support for trauma services. I, P-I Trauma Coordinator (funded) (C) Guidelines: Roles and responsibilities may include administration, clinical, educational, research or quality improvement-related activities. 2.5 The interdisciplinary advisory committee provides guidance throughout the development, management and ongoing quality improvement of trauma services. Guidelines: The advisory committee includes representatives from the various teams involved in trauma care such as emergency department, surgical care, diagnostic services, critical care and rehabilitation. The roles and responsibilities of the advisory committee include surveillance, supporting educational and research activities, and promoting injury prevention programs. 3.0 The trauma centre collects and analyzes information about the need for trauma services. 3.1 The trauma centre collects information about each trauma patient, including diagnosis, treatments and interventions. Criterion Type: High and Indicator (Mortality Rate and Unplanned Readmission) Guidelines: The trauma centre collects and shares information about trauma cases with the trauma system for planning purposes and to help monitor adherence to trauma protocols. IV, P-I, A. Trauma System Integration and L. Injury Surveillance Participation in System Injury Surveillance (A) Presence of Trauma Registry (L) Page -10- Pilot Version (July 5 2013)
3.2 The trauma centre submits information on eligible trauma cases to the provincial/regional trauma registry. 3.3 The trauma centre submits information on eligible trauma cases to the National Trauma Registry Comprehensive Data Set (NTR CDS). Guidelines: IV and V trauma centres are not required to submit information on trauma cases to the national trauma registry but should facilitate access to this information as required. 3.4 The trauma centre uses information on injury rates and trauma cases to plan and design trauma services. Guidelines: This information helps the trauma centre understand the demand for trauma services in order to plan for trauma services and the resources needed to support them. 4.0 The trauma centre promotes safety through various injury prevention activities. 4.1 The trauma centre analyses information about injury rates to identify the risk factors for trauma in the population it serves. Criterion Type: High Guidelines: Higher level trauma centres take a leadership role in identifying emerging trends by analyzing surveillance data and helping the trauma system identify targeted injury prevention programs. Examples of risk factors include not wearing a seat belt, drinking and driving and substance abuse. Participation in National Trauma Registry (CDS) (A) Contribution to NTR (comprehensive data set) (L) Trauma Registry formally integrated within the Trauma Program (L) A. Trauma Systems Integration and N. Injury Prevention Page -11- Pilot Version (July 5 2013)
4.2 The trauma centre contributes to the development of injury prevention policies based on injury rates and risk factors. Guidelines: Higher level trauma centres play an advocacy role in developing injury prevention policies. Examples include policies for reducing road traffic injuries or youth violence. 4.3 The trauma centre participates in injury prevention programs based on injury rates and risk factors. Guidelines: Higher level trauma centres are actively involved in injury prevention efforts that are in line with the trauma system s mandate. Examples include programs on domestic violence awareness, alcohol and substance abuse prevention, and coping and conflict resolutions skills for adolescents. 4.4 The trauma centre has a person assigned to lead its injury prevention programs. 4.5 The trauma centre s injury prevention programs include screening for mental health issues and interpersonal violence. I, II, P-I, I, II, P-I, I,II, P-I, I,II, P-I Leadership for regional IP policy development (N) Injury Prevention (A) Injury prevention and control program participation (N) Injury prevention coordinator (funded) (N) Page -12- Pilot Version (July 5 2013)
4.6 The trauma centre s injury prevention programs include alcohol and substance abuse screening and intervention. Criterion Type: Indicator (Chemical Dependence Screening) Guidelines: Alcohol and substance abuse are significant risk factors for injury. Higher level trauma centres are expected to screen patients for alcohol and substance abuse and offer appropriate interventions to help prevent re-occurrence. 5.0 The trauma centre has sufficient resources to provide quality trauma care. 5.1 The trauma centre has a dedicated funding model for trauma services. Criterion Type: High Guidelines: The funding model is in line with the roles and responsibilities of the trauma centre including medical leadership, administration, injury prevention programs, communication, surveillance, quality improvement activities, staffing, dedicated trauma units/areas, and equipment. 5.2 The trauma centre dedicates resources to provide priority treatment to all major trauma patients. Guidelines: The trauma centre prioritises resources such as staff, diagnostic services and operating rooms to the care of the major trauma patient ensuring immediate access to required care. I,II, P-I Alcohol and substance abuse Screening Programs (N) Alcohol and substance abuse Intervention Programs (N) B. Hospital Commitment and D. Trauma Services Demonstrated financial support to trauma program (B) Funding for trauma team leader program (B) Trauma Registry participation/funding (B) Financial support for leadership roles (B) Demonstrated commitment to priority treatment of severely injured patients (B) Page -13- Pilot Version (July 5 2013)
5.3 The trauma centre has a no refusal policy for receiving major trauma patients within the trauma system. 5.4 The trauma centre determines the number and mix of staff and service providers needed to provide trauma services as per level requirements. Guidelines: The number and mix of staff and service providers required will vary for each level of trauma care. Higher level trauma centres are expected to have an administrative structure in place to oversee the trauma program, and provide comprehensive trauma-related surgical care services such as orthopedic, spine and neurosurgery. 5.5 The trauma centre has a 24 hour trauma response team. Guidelines: The trauma response team may include emergency physicians and nursing staff, general surgeons, specialty surgeons and critical care nurses. Pediatric subspecialty training is required for P-I. 5.6 The trauma response team has a leader ready to respond within 20 minutes of request. Criterion Type: Indicator (Trauma Team Leader Response Time - Optional) I, II, P-I, I, II, P-I, No refusal policy for major trauma (B) Assure adequate resources and staff (as per level requirements) (B) 24 hour trauma team response to include: Trauma team leader (max 20 min response) (D) 24 hour trauma team response to include: Trauma team leader (max 20 min response) (D) Page -14- Pilot Version (July 5 2013)
5.7 The trauma centre provides 24-hour coverage for trauma-related surgical care services. Guidelines: Higher level trauma centres provide comprehensive trauma-related surgical care services, including: Orthopedic Surgery (I,II, III, P-I and )* Neurosurgery (I,II, P-I and )* Plastic Surgery (I, II and P-I)* Spine Surgery (I and P-I)* Burn Surgery (I and P-I)* Vascular Surgery (I, II and P-I) Endovascular Services (I and P-I) Urology (I, II and P-I)* Gynecology and Obstetrics (I, II and P-I)* Pediatric Surgery (I and II not essential if provided at a dedicated alternate site, P-I and ) Ophthalmology (I, II and P-I)* Otolaryngology (I, II and P-I)* Dental/Oral and Maxillofacial Surgery (P-I)* * Pediatric subspecialty training is required for P-I. As per level reqs. 24-hour hospital coverage by the following surgical services (D) Page -15- Pilot Version (July 5 2013)
5.8 The trauma centre provides access to trauma-related surgical care services within 30 minutes of request. Guidelines: The following trauma-related surgical care services are available on call with a 30 minutes maximum response time: Orthopedic Surgery (I,II, III, P-I and )* Neurosurgery (I,II, P-I and )* Vascular Surgery (I, II and P-I) Gynecology and Obstetrics (I, II and P-I)* Pediatric Surgery (I and II not essential if provided at a dedicated alternate site, P-I and ) * Pediatric subspecialty training is required for P-I. 5.9 The trauma centre provides access to non-surgical specialities for trauma patients as per level requirements. Guidelines: Non-surgical specialties for trauma patients include: Emergency Medicine ( IV, P-I and )* Radiology ( IV, P-I and )* Anesthesia ( IV, P-I and )* Critical Care ( P-I and )** Cardiology (I, II, P-I and )* Hematology Transfusion Medicine (I, II, P-I and )* Infectious Diseases (I, II, P-I and )* Internal Medicine ( IV, P-I and )** Nephrology (I, II, P-I and )* Psychiatry (I, II, P-I and )* Psychology (I, II, P-I and )* Physiatry (I, II and P-I)* As per level reqs. As per level reqs. Non-Surgical Specialties for care of the trauma Patient (D) Page -16- Pilot Version (July 5 2013)
Social Work () Child Life (P-I and ) Family Support Programs and Spiritual Care () Child Protection Services (P-I and ) *Pediatric subspecialty training is required for P-I. **Pediatric subspecialty training is required for P-I and. 5.10 The trauma centre uses information technology such as telehealth to ensure access to specialists with expertise in trauma. Guidelines: Telehealth can be used to increase access to trauma services when rural or distance issues prevent equitable access to quality trauma care. Telehealth usually involves smaller centres with limited resources connecting to trauma expertise in larger centres. 6.0 The trauma centre has qualified and knowledgeable staff and service providers in trauma. 6.1 The trauma centre s emergency physicians and trauma team leader are trained in Advanced Trauma Life Support (or equivalent). Criterion Type: High A. Trauma System Integration, E. Emergency Department and M. Trauma Research Personnel and Practice: Designated chief, certified Emergency physician (E) ATLS/or equivalent education of Trauma Team Leaders and Emergency Physicians (E) Page -17- Pilot Version (July 5 2013)
6.2 The trauma centre s emergency nurses have completed the Trauma Nursing Core Course from the Emergency Nurses Association (or equivalent). Criterion Type: High 6.3 The trauma centre orients new staff and service providers on its trauma services. Guidelines: The orientation is specific to trauma services and covers inter-team functioning; linkages with the various teams involved in trauma care such as emergency department, surgical care, diagnostic services, and critical care; and trauma protocols. 6.4 The trauma centre uses information from performance evaluations to identify training and/or professional development needs for trauma services. Guidelines: The trauma centre maintains a qualified and competent workforce in trauma by regularly evaluating training and/or professional development needs and dedicating resources accordingly. 6.5 The trauma centre provides staff and service providers with the opportunity to participate in ongoing professional development activities related to trauma care. Guidelines: For example, TAC maintains information on upcoming conferences and educational courses related to trauma on its website. TNCC/or equivalent trauma nursing education (E) Page -18- Pilot Version (July 5 2013)
7.0 The trauma centre promotes research and innovation in the field. A. Trauma System Integration and 7.1 The trauma centre participates in research activities to promote excellence and innovation in trauma. Criterion Type: Excellence and Innovation Guidelines: Research activities may include epidemiology studies, or clinical research related to trauma care and outcomes. The trauma centre should use applicable research and ethics protocols to obtain patient and family consent to participate. Excellence and innovation is one of the four components of the Distinction program that provides Trauma systems with the opportunity to highlight outstanding achievements in their field. Trauma systems are asked to submit one excellence and innovation project or initiative that has enhanced the quality of trauma services. M. Trauma Research I, P-I Academics and Scholarship (A) 7.2 The trauma centre shares research results internally, with other trauma centers and the public. I, Initiation, participation and dissemination of trauma research (M) Page -19- Pilot Version (July 5 2013)
Providing Coordinated Trauma Care 8.0 The trauma centre works with partners within the trauma system to get the right patient to the right place at the right time. 8.1 The trauma centre has partnerships with surrounding Emergency Medical Services (EMS) and trauma centers to coordinate trauma services within the trauma system. Criterion Type: High Guidelines: Coordinating trauma services includes patient flow, linkages, and expected roles and responsibilities across the trauma care continuum in line with the trauma system agreements. 8.2 The trauma centre has internal partnerships with various services to coordinate trauma care, including the emergency department, critical care, diagnostic services, and surgical care. Criterion Type: High Guidelines: Trauma care is a collaborative process that involves various services within the trauma centre. Internal partnerships help maintain a quick response to trauma cases by prioritizing trauma patients (e.g. dedicated operating room time for urgent cases). Section VI Criteria for Trauma Centres D. Trauma Services Page -20- Pilot Version (July 5 2013)
9.0 The trauma centre immediately assesses and manages the trauma patient upon arrival at the ED. 9.1 The ED activates the institutional trauma response team protocol. Criterion Type: Protocol (Trauma Response Team Activation) and Indicator (Trauma Response Team Activation) Guidelines: The protocol addresses triaging, assessing and managing trauma patients upon arrival. This includes criteria for identifying a major trauma patient and activating the trauma response team. The ED uses agreed upon triage levels such as the Canadian Triage and Acuity Score (CTAS) to conduct the triage assessment. This helps the ED prepare for the arrival of the trauma patient, and ensures that a designated team member is notified as soon as the trauma patient arrives at the ED. The protocol is injury specific including head and face, airway/chest, abdomen, spine, fracture, abrasion, amputation and burn assessments, and population specific such as pediatric, geriatric and pregnancy assessments. Pediatric subspecialty training is required for P-I and. For protocol examples, refer to the American College of Surgeons Trauma Programs and the Eastern Association for the Surgery of Trauma. 9.2 The trauma response team immediately responds to requests for evaluation of a trauma patient in the ED. Criterion Type: High and Indicator (ED Length of Stay) Guidelines: This is particularly important for trauma patients who arrive by modes other than EMS where the ED did not receive pre-notification. D. Trauma Services and E. Emergency Department Criteria for identifying major trauma patient/tta (E) Trauma Team Activation Process (E) Communication and Transfer guidelines (E) Use of trauma practice guidelines (E) CTAS utilization (E) Use of trauma practice guidelines (E) Page -21- Pilot Version (July 5 2013)
9.3 The ED gathers information about vital signs, severity of injuries and medications. 9.4 The ED has access to trauma specific equipment as per level requirements. Guidelines: The following is the list of trauma specific equipment required in the ED: Advanced airway management equipment including surgical airway for adults and children () Broeslow tape () Central and peripheral vascular access including intraosseous equipment ()* Chest tubes ()** Fracture stabilization and traction equipment ()* Monitors (transport, bedside, fetal) ( P-I and ) Portable or overhead X-ray equipment ( IV, P-I and ) Portable ultrasound for FAST (I and II) Rapid infusion warmer ( P-I and ) Surgical equipment (i.e. DPL, thoracotomy tray) ( P-I and )* Tourniquets ( IV, V and P-I) Trauma resuscitation room ( P-I and ) Universal Precautions equipment () Vascular Doppler ( P-I and ) Warming devices (e.g. Bair hugger, warm blankets) ( IV, P-I and ) * Pediatric subspecialty training is required for P-I. ** Pediatric subspecialty training is required for P-I and. As per level reqs. Use of trauma practice guidelines (E) Trauma Specific Equipment required in the Emergency Department (ED) Page -22- Pilot Version (July 5 2013)
9.5 The ED has access to general surgical consultation within 20 minutes of request. Guidelines: Pediatric subspecialty training is required for P-I and. 9.6 The ED has access to other surgical consultation as required within 30 minutes of request. Guidelines: Examples include orthopedics, neurosurgery, and plastic surgery. Pediatric subspecialty training is required for P-I. 9.7 The ED has access to advanced airway intervention capabilities 24 hours a day. Guidelines: Pediatric subspecialty training is required for P-I and. 10.0 The trauma centre has timely access to laboratory and transfusion services for trauma care. 10.1 The trauma centre has access to on-site laboratory and transfusion services 24 hours a day. Criterion Type: High Guidelines: Access to on-site laboratory services includes point-of-care testing. I, II, P-I, IV, P-I, General Surgery emergency department bedside consultation (per defined local protocol, max 20 min response) (D) Other surgical consultation as required (max 30 min response) (D) In house advanced airway intervention capability at all times (D) F. Blood Bank and Laboratory System Available on site 24 hours per day (F) Page -23- Pilot Version (July 5 2013)
10.2 The trauma centre has a massive transfusion protocol. Criterion Type: Protocol (Massive Transfusions) and Indicator (Massive Transfusions - Optional) Guidelines: Massive transfusion protocols contribute to improved communication and blood product availability. The protocol specifies who can activate the protocol and when. Pediatric subspecialty training is required for P-I and. 10.3 The trauma centre has access to unmatched blood within 10 minutes of request. 10.4 The trauma centre s laboratory and transfusion services participate in external quality control programs including inter-laboratory comparisons. Guidelines: The external quality control program is based on the laboratory's examination procedures and scope of analysis and is appropriate to the examination and interpretations provided by the laboratory. I, II, P-I, Formalized Massive transfusion protocol (F) Blood bank system capable of providing unmatched blood within 10 minutes (F) Accredited by Canadian Blood Services and labs (F) Page -24- Pilot Version (July 5 2013)
11.0 The trauma centre has timely access to diagnostic imaging services. G. Diagnostic and Interventional 11.1 The trauma centre has radiology protocols for adult, pregnant and pediatric trauma patients. Criterion Type: Protocol (Radiology) IV, P-I, Radiology Radiology Protocols for imaging of Trauma patients (including pediatric) (G) 11.2 The trauma centre has access to plain film radiography services on-site. Criterion Type: High 11.3 The trauma centre has access to a technologist within 30 minutes of request. 11.4 The trauma centre has access to a radiologist within 30 minutes of request. Guidelines: Pediatric subspecialty training is required for P-I and. 11.5 The trauma centre has access to interventional radiology including angiography services 24 hours a day with a 1 hour response time. I, II, P-I, III, IV, V I, II, P-I, I, II, P-I, Immediate plain film radiography (in-house tech) (G) Technologist on Call with 30 min response (G) Radiologist consultation (30 min) (G) Angiography available 24/7 with 1 hour response (G) 11.6 The trauma centre has timely access to ultrasonography services. 11.7 The trauma centre s CT services are located adjacent to the ED. I, II, P-I, Ultrasonography (G) CT Adjacent to Emergency Department (G) Page -25- Pilot Version (July 5 2013)
11.8 The trauma centre has timely access to Computed Tomography (CT) services on-site. I, II Immediate CT (in-house tech) (G) Criterion Type: Indicator (Time to CT Scan - Optional) 11.9 The trauma centre has access to a CT Technologist within 30 minutes of request. 11.10 The trauma centre has timely access to Magnetic Resonance Imaging (MRI) services. 11.11 The trauma centre has access to the provincial/regional Picture Archiving and Communication System (PACS) or an equivalent system. Guidelines: PACS facilitates access, transmission and storage of medical records and diagnostic images from multiple modalities (e.g. ultrasound, MRI and CT services). III, IV, I, II, P-I, CT Technologist on Call with 30 min response (G) Access to magnetic resonance imaging (G) Provincial/Regional PACS or equivalent system (G) Page -26- Pilot Version (July 5 2013)
12.0 The trauma centre has timely access to surgical care services for trauma care. B. Provincial and Quaternary Trauma Services, D. Trauma Services and H. Operating Room 12.1 The trauma centre has access to surgical care services on-site 24 hours a day, including appropriate nursing staff and equipment for immediate surgeries. Criterion Type: High and Indicator (Proportion of Patients with Epidural and Subdural Brain Hematoma Receiving Craniotomy within 4 Hours Optional, and Proportion of Patients with an Open Long Bone Fracture who Undergo Surgery within 6 Hours of Arrival Optional) I, II In-house 24 hour operating room nursing staff available for immediate surgery with the necessary equipment (H) Access to operative resources in a timely manner (B) 12.2 The trauma centre prioritizes trauma cases as part of its Operating Room (OR) booking policy. I, II, P-I, Demonstrated formalized prioritization system for trauma cases (H) 12.3 The operating room booking policy dedicates OR time for urgent trauma cases such orthopedics and plastic surgeries. 12.4 The trauma centre has a trauma/general surgeon ready to respond within 20 minutes of request. Guidelines: Pediatric subspecialty training is required for P-I. I, II Availability of protected OR time for urgent trauma cases (i.e. ortho/plastics) (H) 24-hour hospital coverage by the following surgical services (D): Trauma Surgeon, General Surgeon (max 20 min ) 12.5 The trauma centre has OR nursing staff available to respond within 30 minutes of request. III, P-I, 30 minute call back for operating room nursing staff for immediate surgery (H) Page -27- Pilot Version (July 5 2013)
12.6 The trauma centre has access to anesthesia within 20 minutes of request. Anesthesia availability within 20 min response time (H) 12.7 The trauma centre has access to perfusion services and core re-warming capability in the operating room. I, II, P-I Perfusion Services and core re-warming capability (H) 13.0 The trauma centre has timely access to critical care services for trauma care. 13.1 The trauma centre has a co-management model for critical care and surgical care services. Guidelines: The trauma centre s critical care and surgical care services share responsibility for managing the trauma patient. It is important to clearly define their roles and responsibilities within the co-management model. 13.2 The trauma centre has a medical leader to oversee critical care services Guidelines: Roles and responsibilities include protocol development and ongoing quality improvement activities. I. Intensive Care Unit Co-management with surgical team (I) Medical Director of Intensive Care (I) 13.3 The trauma centre has a physician trained in intensive care available 24 hours a day. Criterion Type: High I, II, P-I, 24 hr in-hospital critical care physician coverage (I) Page -28- Pilot Version (July 5 2013)
13.4 The trauma centre manages trauma patients using a closed Intensive Care Unit (ICU) model. Criterion Type: Indicator (Unplanned Intensive Care Admission - Optional) Guidelines: In a closed ICU model, trauma patients are transferred to the care of an intensivist assigned to the ICU on a full-time basis. 13.5 The trauma centre has surgical critical care protocols for trauma patients. Criterion Type: Protocol (Surgical Critical Care) and Indicator (VTE Prophylaxis and Tracheal Intubation- Optional) I, II, P-I, Closed ICU model (I) Trauma practice guidelines (I) Guidelines: Surgical critical care protocols are specific to trauma patients and may cover pain management, nutritional support, stress ulcer prophylaxis, and venous thromboembolism. For protocol examples, refer to the American College of Surgeons Trauma Programs and the Eastern Association for the Surgery of Trauma. 13.6 The trauma centre s surgical care protocols include assessing trauma patients for nutritional support as needed. Guidelines: The protocol addresses the route to deliver nutrition to the trauma patient, specifically patients with multisystem injuries including severe head injuries, burns, and fractures. For protocol examples, refer to the Eastern Association for the Surgery of Trauma Guidelines. Page -29- Pilot Version (July 5 2013)
13.7 The trauma centre has protocols to transfer trauma patients to and from another level of ICU. 13.8 The trauma centre has a no refusal policy for receiving major trauma patients from another ICU level within the trauma system. I, II, P-I, Transfer Protocols to/from higher level ICU (I) No refusal policy for major trauma patient (I) 14.0 The trauma service provides comprehensive inpatient trauma services. D. Trauma Services and J. Inpatient Trauma Units 14.1 The trauma centre has a surgeon-led interdisciplinary team for overseeing inpatient trauma services. I, II, P-I, A Surgeon-led multi-disciplinary inpatient trauma service within the hospital (D) Criterion Type: High Guidelines: The interdisciplinary team may include nurses, physiotherapists, physiatrists, massage therapists, speech language therapists, psychologists, psychiatrists and social workers. Pediatric subspecialty training is required for P-I. Dedicated allied health resources (J) 14.2 The trauma centre has guaranteed access to beds for trauma patients. I, II, P-I, 14.3 The trauma centre manages trauma patients on a dedicated trauma unit I, II, P-I, or a clustered area. Guaranteed Access to Trauma Beds (J) Dedicated Trauma Unit (cohorting trauma patients) (J) Guidelines: A trauma unit is an area with beds designated for the management of trauma patients, located in a geographically discrete area, and consistently receiving trauma services. If trauma units are not available, there is a process to identify and group trauma patients together. This process facilitates the use of trauma protocols and services from specially trained staff and service providers. Page -30- Pilot Version (July 5 2013)
14.4 The trauma centre has a process to identify and list all trauma patients daily. 14.5 The trauma centre conducts a daily case review of trauma patients to identify and review their case needs. Criterion Type: Indicator (Length of Stay and Tertiary Survey - Optional) Guidelines: Patient case reviews include a discussion of the assessment, current status, rehabilitation status and needs, discharge planning, other concerns as indicated by patient s condition. 14.6 The trauma centre assesses the patient s trauma rehabilitation needs within a timely manner after admission. Guidelines: It s important to identify trauma patients who would benefit from early rehabilitation services. The trauma centre is encouraged to monitor its responsiveness by setting and tracking times for assessment. Standardized and validated assessment tools should be used to determine cognitive and functional impairments (e.g. Functional Independence Measure (FIM) and SF-36 Health Survey). 14.7 The trauma centre screens trauma patients for mental health issues and follows-up within a timely manner after admission. Guidelines: The assessment may include emotional status, including suicidal or self-harming behaviours; and personality and behavioural characteristics. Examples include the Mini-International Neuropsychiatric Interview (MINI). I, II, P-I, I, II, P-I, I, II, P-I and Capacity for intermediate care with monitoring (J) Trauma Practice Guidelines (J) Page -31- Pilot Version (July 5 2013)
14.8 The trauma centre has access to dedicated allied health resources for trauma services. I, II, P-I, Guidelines: Examples include physiotherapy, occupational therapy and speech therapy. Helping Patients and Families Cope with Trauma 15.0 The trauma centre provides comprehensive information to patients and their families on trauma care. 15.1 The trauma centre has identified which team members are responsible for providing information to patients and their families about coping with trauma. Criterion Type: High 15.2 The trauma centre provides information to patients and their families that is appropriate to their needs and phase of care or recovery. Guidelines: Information is provided in an interactive way and addresses possible issues or life style changes and strategies to address these changes. Information may also address injury prevention strategies to help prevent recurrence such as alcohol and substance abuse interventions, and coping and conflict resolutions skills for adolescents. Information is provided in a variety of languages and formats (written or verbal), and specific to patient and family needs and impairments. Section VI Criteria for Trauma Centres D. Trauma Services Page -32- Pilot Version (July 5 2013)
15.3 The trauma centre provides emotional support and counseling to patients and their families to help them adjust and cope with the effects of trauma. Guidelines: Experiencing traumatic events may lead to mental health issues such as Post-Traumatic Stress Disorder (PTSD) or Acute Stress Disorder. Interpersonal violence, suicidal or self-harming behaviors may also be a contributing factor. Patients and their families are provided with education materials and access to counseling programs to help them cope with the effects of trauma. For example, the International Society for Traumatic Stress created a variety of public education pamphlets and fact sheets on trauma-related issues. If the trauma centre is not able to provide emotional support and counseling services, they refer patients and their families to the appropriate services (e.g. family physician, community-based organizations). 15.4 The trauma centre documents the information provided to patients and their families prior to discharge. Guidelines: Documentation describes the timing, the type of information provided, materials shared and content reviewed, family members that were present, duration of session, and who provided the information. Page -33- Pilot Version (July 5 2013)
16.0 The trauma centre prepares patients and their families for discharge or transfer. 16.1 The trauma centre initiates discharge planning from time of admission. Criterion Type: High Guidelines: Discharge planning is a component of the initial care management plan development. It should be an ongoing dialogue with the patient and family. Specific team members such as nursing or case managers should be designated to ensure discharge planning discussions occur for all patients and their families. 16.2 The trauma centre uses formal referral criteria to identify trauma patients who are ready for inpatient rehabilitation, and makes a referral for inpatient rehabilitation services. Criterion Type: Indicator (Change in Functional Status - Optional) Guidelines: The trauma centre completes assessments and determines when patients meet defined criteria for rehabilitation and communicates this to the referral rehabilitation centre for timely transfer. D. Trauma Services Page -34- Pilot Version (July 5 2013)
16.3 The trauma centre develops a transition and follow-up plan with input from patients and their family that includes information about ongoing recovery and contact information for follow up. Guidelines: Transitions from inpatient care and reintegration into the community are enhanced when patients and their families have comprehensive information about ongoing health and expected progression for further recovery, transitions and end of service, changes that may be required in their environment, work-life, and financial issues. This aids in reducing the stress of transition to home and community, and also helps minimize delays in discharge. 16.4 The trauma centre has a list of community services and helps patients and their families access these services upon discharge. Guidelines: Community services for patients and their families include primary care physicians, community-based rehabilitation, homecare services, emotional support and counseling, trauma survivor support groups, and vocational counseling. 16.5 The trauma centre effectively transfers information about diagnosis, tests, interventions, medications, referrals, psychosocial status, and family situation to the patient s primary care provider. Guidelines: Effective communication is critical at transition points. The trauma centre should use mechanisms for timely and consistent transfer of information at transition points and document the time that transfer of information has occurred. Page -35- Pilot Version (July 5 2013)
16.6 When patients are referred to inpatient rehabilitation services, the trauma centre effectively transfers information about diagnosis, tests, outstanding tests to be done, interventions, current medications and medication changes, family situation, psychosocial status, and referrals. Guidelines: Effective communication is critical at transition points. The trauma centre should use mechanisms for timely and consistent transfer of information at transition points and document that transfer of information has occurred. 16.7 Following transition, the trauma centre has a process to evaluate the effectiveness of the transition, and uses this information to improve its transition planning. Guidelines: The trauma centre reviews information on a sample of trauma patients, families, or referral organizations to monitor the results of the transition or discharge, and any follow-up plans. The trauma centre verifies that patient and family needs have been met, and uses this information to improve transition planning. 17.0 The trauma centre provides respectful end-of-life care to patients and their families. 17.1 The trauma centre has a protocol for providing end-of-life care. Criterion Type: High Guidelines: End-of-life care uses a collaborative approach to address the needs of patients and their families, including bereavement counselling. Page -36- Pilot Version (July 5 2013)
17.2 The trauma centre supports family members and friends throughout and following the death of a patient, as appropriate to resources and capacity. Guidelines: The trauma centre encourages the patient s family and friends to use existing support systems in the community. When these are insufficient, or when family and friends are identified as being at risk for complex grief reactions, the trauma centre facilitates access to bereavement services, including volunteer support or professional services. 17.3 The trauma centre follows existing protocols for organ and tissue donation. Criterion Type: Protocol (Organ and Tissue Donation) Evaluating the Quality of the Trauma Centre 18.0 The trauma centre has an information system that provides accurate and timely information for planning and evaluating trauma services. 18.1 The trauma centre has security, back-up, and confidentiality systems in place to protect trauma-related data in line with applicable legislation. Criterion Type: High Section VI Criteria for Trauma Centres L. Injury Surveillance Meets privacy act regulations (L) Page -37- Pilot Version (July 5 2013)
18.2 The trauma centre monitors and validates the quality of data the trauma information system. Guidelines: The trauma centre relies on accurate information on trauma services for planning and quality improvement activities, and for surveillance activities. The trauma system can monitor and validate its data by conducting chart audits to review accuracy of information. Examples of other data sources used for planning and quality improvement include the Trauma Quality Improvement Program, the Canadian Institute of Health Information (e.g. Discharge Abstract Database and National Ambulatory Care Reporting System), and mortality data sets. 18.3 The trauma centre regularly reviews and improves the trauma information system. Guidelines: For example, the trauma information system can be improved by adding new data fields to capture more information, and generating new reports. Page -38- Pilot Version (July 5 2013)
19.0 The trauma centre continuously evaluates the quality of trauma services and makes improvements as needed. 19.1 The trauma centre has a Performance Improvement and Patient Safety (PIPS) program to evaluate how trauma services are delivered within the trauma centre. Criterion Type: High Guidelines: The PIPS program is an organized and comprehensive review of trauma care and patient outcomes. Evaluation results can be used to improve the quality of trauma care to the population served, to drive research, and contribute to system integration or surveillance initiatives. Quality improvement is a collaborative process that includes the medical and administrative leaders and the interdisciplinary advisory committee. 19.2 The trauma centre uses the trauma information system to generate regular reports about performance and adherence to trauma protocols. Criterion Type: Indicator (Complication Rate) Guidelines: The trauma centre may summarize the information by injury and/or population type. K. Performance Improvement and Patient Safety (PIPS) Programs and L. Injury Surveillance Continuous multi-professional PIPS Program (K) Trauma PIPS committee (K) Capacity for ad hoc reporting (L) Review of hospital trauma caseload (inpatient, ambulatory) (L) Standardized regular reports to program Leadership (L) Page -39- Pilot Version (July 5 2013)