An integrated, coordinated system of trauma care has been shown to reduce injury-related deaths by improving timely access to specialized care
There is, however, wide variation in how long it takes to get a severely injured patient to a trauma centre in Ontario.
Trauma systems improve by systematically assessing performance and outcomes. Ontario does not have such a performance improvement system in place.
Last weeks’ story on healthydebate.ca described Ontario’s system of trauma hospitals, and how rapid access to sophisticated trauma care can save the lives of severely injured patients. You can read that story here. This week, we examine how the performance of Ontario’s trauma system is being assessed and improved.
Patients who live in regions distant from a trauma centre are at a threefold higher risk of dying in the emergency department than those who live close to a trauma centre. While only 15% of its population lives more than an hour away from one of Ontario’s eleven trauma centres, they account for 37% of all deaths from injuries. In Ontario, if patients are transported directly from the scene of an accident to a trauma centre, the transfer time is an average of 62 minutes. If they are first transferred to a closer hospital, the transfer time to a trauma centre is over 6 hours.
What is being done to monitor and improve access to trauma care in Ontario?
Trauma System Processes
In Ontario, Emergency Medicine Services (EMS) providers who arrive at the scene of an accident or injury assess the severity of a patient’s injuries, and must decide whether the injuries are severe enough to warrant transfer directly to a trauma centre. EMS providers use trauma triage guidelines, which say that if the scene of the injury is more than a 30 minute drive from a trauma centre, and if an air ambulance is not available to transport the patient from the scene, the patient should be transported to the closest hospital.
Bruce Sawadsky, chief of staff for Ornge Transport Medicine (which provides air emergency medical services and medical transport in Ontario) says that the “trauma triage guidelines should be highly sensitive so that we do not miss patients that require direct transport to a trauma centre. However, they should also be as specific as possible so that helicopters are utilized primarily for patients who truly need transport to a trauma centre, thus ensuring the cost-effective use of helicopters”.
If a trauma patient is taken to the closest hospital and determined by doctors to require care at a trauma centre, there can be three main causes of a delay in transfer. According to Blair Bigham, an advanced care flight paramedic with Ornge, there can be delays in making the decision to transport, delays in finding transport resources, and finally delays in the transport itself. He describes the inter-facility transfer process as one with “multiple steps, each with potential for delay”.
In Ontario, there are 72 separate land ambulance services which are based in municipalities and regions. There are also a number of separate dispatch systems across the province. There is, however, one air transport system, Ornge, which provides air and land transport for very ill and critically injured patients, and has a fleet of 11 helicopters in service and 7 fixed wing aircraft in service at bases across Ontario. These multiple providers are overseen and accredited by the Emergency Health Services Branch of the Ontario Ministry of Health and Long-Term Care.
In other provinces, such as Nova Scotia, the groups involved in trauma care are more integrated. John Tallon, director of the Nova Scotia trauma system, describes how Nova Scotia combined 55 independent ambulance systems to create “one integrated ground ambulance system as the single provider of ambulance care”. The province also improved communications and protocols for bypassing intermediate trauma care, focusing the system on “getting the right patient to the right place at the right time”.
Improving Access to Trauma Care in Ontario
In 2006, the Ontario Ministry of Health and Long-Term Care asked a Trauma Expert Panel to “provide timely expert advice on improving the access, quality, efficiency, safety and accountability of trauma services”. One of the panel’s recommendations was to develop “target times … within which trauma patients waiting in a primary sending hospital are transported to a lead trauma hospital”.
However, five years later no such targets have been clearly articulated, nor is there an established province-wide program for improving the quality of the trauma system. Bernard Lawless, a surgeon and provincial lead for Critical Care and Trauma says that while targets have not been finalized, Ontario has “implemented a number of strategies through the provincial Critical Care Strategy which establishes the necessary processes and partnerships” to develop provincial or regional targets. Lawless says that the Ontario government “wanted to look at the capacity and capability of lead trauma centres, and more broadly all [Ontario] acute care hospitals that look after injured patients” first, to establish what resources exist at the designated lead trauma hospitals and regional hospitals for managing injured patients.
Avery Nathens, director of trauma at St. Michael’s Hospital notes that other jurisdictions have put in place ways to “monitor the performance of EMS, rates of appropriate and inappropriate triage, and timeliness to accessing care”. For example, Washington State, provides publicly available data on the outcomes of trauma patients’ cared for in all hospitals in the state. The American Trauma Society has a website which allows users to identify the trauma centre closest to their location. Ontario has nothing like this in place. The Ontario Trauma Registry collects data on all patients who visit one of the eleven provincial trauma centres. However patients who die at the scene, or who are hospitalized or die in other hospitals, are not part of the registry, and the outcomes at the trauma centres are not regularly reported.
Ontario is a large province with heavily populated areas in the south, and sparse populations in the remote areas of the province. Reducing all variation in access to trauma care is likely not possible. However evidence and practices from other jurisdictions show that much more can be done to improve access and reduce transfer times.
Nathens says that better monitoring of system performance, which includes setting targets and working with referring providers to better understand their needs and identify barriers to providing optimal early care, could have a tremendous impact. He also suggests that the development of standardized criteria to help identify which patients should be transferred to a trauma centre “could go a long way in helping patients access the right care at the right place at the right time.”