CIHR Team in Trauma System Development in Canada: Overcoming the challenges of geography through an evaluation of structure and process

Principal Investigators: Nathens, Avery B; Gagliardi, Anna R; Pong, Raymond W; Rubenfeld, Gordon; Schuurman, Nadine C
St. Michael's Hospital (Toronto, ON)

Each year, approximately 15,000 Canadians die as a result of injury and over 225,000 are hospitalized. Although injury prevention strategies play an important role in reducing the toll of injury, the care that patients receive when an injury occurs can dramatically affect their chance of survival. In fact, when injured patients are taken directly to a designated trauma centre—even if it means bypassing a closer hospital to get the patient there—the chance of survival improves by a whopping 25%.

These trauma centres, which operate at all hours with highly specialized staff and sophisticated diagnostic equipment, don’t exist in every hospital. In Ontario, for example, only 11 of its hospitals (out of more than 150) have them. That means that the paramedics who arrive at the scene of a car accident, for example, must assess the severity of a patient’s injury and decide whether the best option is the nearest hospital or one with a trauma centre.

Unfortunately, not all patients who require a trauma team get one. The CIHR Team in Trauma System Development in Canada (CIHR Team) conducted a study in Ontario and found that severely injured elderly patients and female patients, in general, were less likely to be taken to trauma centres.

“When we looked at patients severely injured as a result of a car crash, 25% were never cared for in a trauma centre and the most striking differences in access were among the elderly patients,” explains Dr. Avery Nathens, senior scientist at Sunnybrook Research Institute in Toronto, Surgeon-in-chief and trauma surgeon, Sunnybrook Health Sciences Centre, and leader of the CIHR Team. “So, we advocated strongly for revisions to the field trauma triage criteria, which is the set of criteria that medics use to determine if patients need to be transported directly to a trauma centre. Working closely with our EMS partners and the Ministry of Health and Long Term Care, we are proud to say that as of early 2015, the province of Ontario now has implemented the most up to date evidence-based criteria.”

Dr. Nathens and his team wanted to address this care gap through a second mechanism, as well, by targeting hospitals that are not designated trauma centres. At these hospitals, it is up to the emergency physician to decide whether the patient should be moved.

“Since distances in the province are significant, we acknowledge that many patients will still be transported first to a local hospital, particularly in more rural environments,” he says. “To overcome barriers to transferring these patients to trauma centres, we rolled out special Trauma Centre Consultation Guidelines, which help care providers in non-trauma centres know when to call CritiCall Ontario [a 24-hour-a-day emergency referral service for hospital-based physicians across Ontario].”

Even when gender- and age-related factors are addressed, however, the reality is that not all Canadians have equal access to specialized trauma care.

“We live in a country that is sparsely populated and has great distances between trauma centres,” explains Dr. Nathens. “Only 69% of the Canadian population lives within one-hour driving distance to a trauma centre. This varies by province, too, so systems need to take into consideration local geography and population distribution to ensure that their populations are well served.”

To overcome these challenges, the CIHR Team would like to see the creation of a more “inclusive” system where a larger number of hospitals participate in the trauma system (at least to the extent that their resources allow). Currently, trauma centres are designated as Level 1 and Level 2, meaning that they care for the most severely injured patients. Many provinces only have this level of designation—meaning that a hospital is either given a designated level or is not considered part of the trauma system. Provinces that have a more inclusive system, however, designate additional hospitals as Level 3 or Level 4 trauma centres. According to Dr. Nathens, these additional designations can improve care.

“While these [Level 3 and Level 4] hospitals don’t have the expertise to take care of every patient, they play an important role in the skilled initial evaluation and management of the most severely injured patients and then transfer them to higher levels of care,” he says. “At the same time, their expertise allows them to keep more patients in their community who can be served locally. Inclusive systems bring more hospitals on board and fill in critical gaps in access to care. They also create communities of practice, with a Level 1 or 2 trauma centres as a hub and their local Level 3 or 4 centres as spokes. This hub and spoke model reduces barriers to transfer and provides ready access to education to providers who might only care for a few severely injured patients each year.”

For Dr. Nathens and the CIHR Team, it’s an exciting time to conduct this research. “Each of our works fills in a piece of the puzzle to better understand where there might be gaps in trauma care,” he notes.

Thanks to the team’s excellent relationship with Critical Care Services Ontario (part of the Ministry of Health and Long-Term Care) and a very engaged group of hospital and EMS providers, they have already effected positive change in Ontario. Their work could lead to additional interventions to ensure more equitable and timely access to quality trauma care for all Canadians.

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