Accessing trauma care in Ontario
Every year nearly 5,000 Ontarians are injured through trauma and require specialized trauma care, which has been proven to save lives.
Many Ontarians think that they can access specialized trauma care at their local emergency department. This is not true.
Timely access to specialized trauma care does not always occur in Ontario.
Melanie Carter was a young woman, whose life was cut short due to a number of factors, including a lack of timely access to trauma care.
Melanie was at a party on a rainy night in May 2007. When she left, Melanie drove a friend’s car because her friend had too much to drink. Melanie also had a few drinks that night, and she was speeding along dark, slick roads in an unfamiliar car. The car careened off the road and flipped, injuring her and the two other passengers. Melanie was severely injured and was rushed by ambulance to a small community hospital, where she waited many hours for an ambulance to transport her to a trauma centre. A few hours after arriving at the trauma centre, Melanie died from her injuries.
Melanie’s mother, Colleen Carter, accompanied her to the trauma centre that night and was devastated when the doctors told her that “timing was of the essence” and that Melanie’s life might have been saved if she had been transported to the trauma centre sooner.
Research demonstrates that time is of the essence in saving the lives of trauma patients. Because Melanie’s tragic story is not unique in Ontario, it raises the question of whether we have the right system in place for rapid access to specialized trauma care when it is needed.
What is the evidence that trauma centres work?
Trauma is a term to describe severe injury, and includes injuries due to motor vehicle accidents, falls from a significant height, blunt injuries or wounds from violence. Trauma is the leading cause of death for Canadians under the age of 45, cutting short many young lives. Trauma also has significant financial costs – Canadians spend nearly $20 billion each year on the direct and indirect costs associated with injury.
There is evidence that dedicated trauma services and systems of trauma care save lives. Major advances in trauma treatment and care have come from the battlefields of the 20th century, and great progress has been made in trauma systems, transport, resuscitation and hospital trauma teams. All are geared towards rapid access of severely injured patients to a specialized team of health professionals working at a centre with access to sophisticated equipment .
A recent study found that care at a designated trauma centre is associated with a 19% reduction in injury-related mortality. The quality of life of those who do survive is also better in patients cared for in trauma centres.
What is a trauma centre?
In Canada, trauma centres are accredited by the Trauma Association of Canada. Accrediation evaluates whether a hospital has the appropriate resources to deliver high quality, immediate care to an injured patient, according to the hospital’s size and the volume of trauma patients it cares for. Not all hospitals in Canada have been accredited.
Trauma teams based at trauma centres consist of doctors (typically general surgeons, anesthesiologists, orthopedic surgeons, emergency specialists and neurosurgeons), nurses, respiratory therapists and others who are available 24/7. This team is immediately mobilized and works together when a severely injured patient arrives at the hospital. It is important to note that a trauma centre is a specialty hospital, not just a hospital comprised of specialty doctors. In a trauma centre, protocols are in place to ensure that the care of the patient meets evidence-based guidelines. In Ontario there is a trauma registry, which collects data on all trauma patients in the province.
Patients access trauma centres in a number of ways. Victims of trauma are assessed on the scene of an accident or injury by a team of paramedics who decide which hospital to transport the patients to. In some cases, because of distance and time constraints, patients are first brought to a local hospitals’ emergency department, where staff assess, resuscitate and care for the injured patient. However if the patient is severely injured and requires specialized trauma care, the patient is transported by air or ground ambulance, to a trauma centre, bypassing closer hospitals that are not trauma centres.
Howard Ovens, an emergency department doctor and director of the Mount Sinai Hospital emergency department says that “not all emergency departments are created equal. The emergency department is the front door to a hospital, and no hospital can be all things to all people. In order to provide the best services we need specialized centres.”
In fact, there are five levels of trauma centre designations. Level 1 and 2 designations are for highly specialized trauma centres, with level 1 centres at teaching and research hospitals, where Level 2 centres are not. A Level 3 trauma centre is a moderate size hospital that provides initial care for major trauma patients and transfers patients in need of complex care to a Level 1 or 2 centre. A Level 4 centre is a major urban hospital that handles large volumes of moderately severe trauma, and has bypass and triage protocols in place to divert major trauma to a Level 1 or 2 centre. Finally, a Level 5 centre is a small rural hospital where most trauma patients are stabilized and transferred to a level 1 or 2 trauma centre as quickly as possible.
Maintaining the trauma skills of staff that work in smaller hospitals can be a challenge because many see very few patients with trauma. Andrew Affleck, director of trauma at Thunder Bay Regional Health Sciences Centre says that “ongoing education is needed for nurses and doctors” in trauma care. Affleck says the family doctors who work in emergency departments of small community hospitals are “expected to be the jack of all trades,” and he argues that education for these professionals should focus on “recognizing when the patient needs to be transferred and what to do while waiting for a transfer.”
What trauma resources are available in Ontario?
Ontario’s trauma system is focused on 11 urban hospitals which have been designated as level 1 or 2 trauma centres, two of which provide trauma care for children. However, not all injuries occur in urban areas. In fact, rural and remote areas have a higher rate of trauma and trauma related-deaths; 15% of Ontario’s population lives more than 1 hour from a major trauma centre, but this population accounts for 37% of trauma deaths. The average time to transport an injured patient from the scene of the injury directly to a trauma centre is 62 minutes; however if a patient is first taken to a local hospital, it takes over 6 hours for the injured patient to reach a trauma centre.
A highly functioning trauma system ensures, as much as geography will allow, that patients with major trauma get rapid access to care at a major trauma centre. This involves not only appropriately resourcing and accrediting the major trauma centres, but also ensuring that Level 3 to 5 trauma centres are resourced and accredited to deal with the trauma they see, and that patients are rapidly transported to the most best centre for definitive care, depending upon the severity of their injury.
Watch a video of Avery Nathens, director of trauma at St Michaels Hospital talk about the existing systems of trauma care in Ontario.
Stay tuned for part 2 of this series, which will review what we know about how well the trauma system works in Ontario.