Evaluations for New Healthcare Environment Commissioning and Operational Decision Making Using Simulation and Human Factors: A Case Study of an Interventional Trauma Operating Room.

PURPOSE: The aim of this article is to provide a case study example of the preopening phase of an interventional trauma operating room (ITOR) using systems-focused simulation and human factor evaluations for healthcare environment commissioning. BACKGROUND: Systems-focused simulation, underpinned by human factors science, is increasingly being used as a quality improvement tool to test and evaluate healthcare spaces with the stakeholders that use them. Purposeful real-to-life simulated events are rehearsed to allow healthcare teams opportunity to identify what is working well and what needs improvement within the work system such as tasks, environments, and processes that support the delivery of healthcare services. This project highlights salient evaluation objectives and methods used within the clinical commissioning phase of one of the first ITORs in Canada. METHODS: A multistaged evaluation project to support clinical commissioning was facilitated engaging 24 stakeholder groups. Key evaluation objectives highlighted include the evaluation of two transport routes, switching of operating room (OR) tabletops, the use of the C-arm, and timely access to lead in the OR. Multiple evaluation methods were used including observation, debriefing, time-based metrics, distance wheel metrics, equipment adjustment counts, and other transport route considerations. RESULTS: The evaluation resulted in several types of data that allowed for informed decision making for the most effective, efficient, and safest transport route for an exsanguinating trauma patient and healthcare team; improved efficiencies in use of the C-arm, significantly reduced the time to access lead; and uncovered a new process for switching OR tabletop due to safety threats identified.

The evolution of trauma surgery at a high-volume Canadian centre: implications for public health, prevention, clinical care, education and recruitment.

BACKGROUND: Trauma centres continue to evolve with respect to clinical care and their impact on public health. Despite improvements in patient outcomes, operative volumes, and therefore maintenance of surgical skills, has become a challenging issue. We sought to determine whether injury demographics and treatments at a high-volume centre changed over time. METHODS: We used the Alberta Trauma Registry to analyze all severely injured (injury severity score [ISS] ≥ 12) patient admissions over a 16-year period (1995-2011). RESULTS: Of the 12,879 severely injured patients requiring admission, there was a 1.5- fold increase in the annual admission rate despite population normalization (p = 0.001). Over the 16-year interval, patients were older with a subsequent lower mortality (p = 0.001) and length of hospital stay (p = 0.007). In patients with the most severe ISS (≥ 48), there was no change in mortality (27%, p = 0.26). In 2011, falls were the most common mechanism compared with motor vehicle crashes (41% v. 23%; p < 0.001); this was a complete reversal compared with 1995 (25% v. 41%). Motorized recreational vehicle and motorcycle injuries also increased (p < 0.001). The mean number of operations performed by trauma surgeons decreased (laparotomies: 67 [17%] in 1995 v. 47 [5%] in 2011, p < 0.001). Thoracotomies and tracheostomies remained unchanged (p = 0.19). CONCLUSION: Clinical care has improved despite an increasing overall volume of severely injured patient admissions. The number of operative interventions performed by trauma surgeons continues to decrease concurrent to a change in injury mechanisms. Despite these improvements, maintenance of technical skills among trauma surgeons has become an important issue.

CONTEXTE: Les centres de traumatologie continuent d'évoluer au plan des soins cliniques et de leur impact sur la santé publique. Malgré certaines améliorations, les résultats pour les patients, le volume opératoire et par conséquent, le maintien des habiletés chirurgicales sont devenus un enjeu délicat. Nous avons voulu déterminer si les caractéristiques démographiques et les traitements en traumatologie ont évolué avec le temps dans un centre qui traite un volume élevé de cas. MÉTHODES: Nous avons eu recours au Registre albertain des traumatismes pour analyser toutes les admissions de grands blessés (indice de gravité des blessures [IGB] ≥ 12) au cours d'une période de 16 ans (1995­2011). RÉSULTANTS: Chez les 12 879 grands blessés ayant dû être hospitalisés, nous avons noté une augmentation selon un facteur de 1,5 du taux annuel d'admissions, malgré une normalisation de la population (p = 0,001). Au cours de cet intervalle de 16 ans, les patients ont graduellement été plus âgés, et la mortalité (p = 0,001) et la durée des séjours hospitaliers (p = 0,007) ont subséquemment diminué. Chez les patients présentant les IGB les plus élevés (≥ 48), on n'a noté aucun changement de la mortalité (27 %, p = 0,26). En 2011, les chutes ont été la cause la plus fréquente des traumatismes, par rapport aux accidents de la route (41 % c. 23 %, p < 0,001), ce qui s'est révélé être un renversement complet par rapport à 1995 (25 % c. 41 %). Le nombre de blessures subies avec des véhicules motorisés récréatifs et des motocyclettes a aussi augmenté (p < 0,001). Le nombre moyen d'interventions effectuées par les chirurgiens en traumatologie a diminué (laparotomies : 67 [17 %] en 1995 c. 47 [5 %] en 2011, p < 0,001). Le nombre de thoracotomies et de trachéotomies est resté inchangé (p = 0,19). CONCLUSION: Les soins cliniques se sont améliorés malgré l'augmentation du volume global d'hospitalisations de patients grièvement blessés. Le nombre d'interventions chirurgicales effectuées par les chirurgiens en traumatologie continue de diminuer parallèlement à une évolution des causes de traumatismes. Malgré ces améliorations, le maintien des habiletés techniques des chirurgiens en traumatologie est devenu un enjeu important.

The right treatment at the right time in the right place: a population-based, before-and-after study of outcomes associated with implementation of an all-inclusive trauma system in a large Canadian province.

OBJECTIVE: To evaluate the implementation of an all-inclusive philosophy of trauma care in a large Canadian province. BACKGROUND: Challenges to regionalized trauma care may occur where transport distances to level I trauma centers are substantial and few level I centers exist. In 2008, we modified our predominantly regionalized model to an all-inclusive one with the hopes of increasing the role of level III trauma centers. METHODS: We conducted a population-based, before-and-after study of patient admission and transfer practices and outcomes associated with implementation of an all-inclusive provincial trauma system using multivariable Poisson and linear regression and Cox proportional hazard models. RESULTS: In total, 21,772 major trauma patients were included. Implementation of the all-inclusive model of trauma care was associated with a decline in transfers directly to level I trauma centers [risk ratio (RR) = 0.91; 95% confidence interval (CI): 0.88-0.94; P < 0.001] and an increase in transfers from level III to level I centers (RR = 1.10; 95% CI: 1.00-1.21; P = 0.04). These changes in trauma care occurred in conjunction with a 12% reduction in the hazard of mortality (hazard ratio = 0.88; 95% CI: 0.84-0.98; P = 0.003) and a decrease in mean trauma patient hospital length of stay by 1 day (95% CI: 1.02-1.11; P = 0.02) after adjustment for differences in case mix. CONCLUSIONS: In this study, introduction of an all-inclusive provincial trauma system was associated with an increased number of injured patients cared for in their local systems and improved trauma patient mortality and hospital length of stay.

The evolution of a purpose designed hybrid trauma operating room from the trauma service perspective: the RAPTOR (Resuscitation with Angiography Percutaneous Treatments and Operative Resuscitations).

Traumatic injury is the leading cause of potentially preventable lost years of life in the Western world and exsanguination is the most potentially preventable cause of post-traumatic death. With mature trauma systems and experienced trauma centres, extra-abdominal sites, such as the pelvis, constitute the most frequent anatomic site of exsanguination. Haemorrhage control for such bleeding often requires surgical adjuncts most notably interventional radiology (IR). With the usual paradigm of surgery conducted within an operating room and IR procedures within distant angiography suites, responsible clinicians are faced with making difficult decisions regarding where to transport the most physiologically unstable patients for haemorrhage control. If such a critical patient is transported to the wrong suite, they may die unnecessarily despite having potentially salvageable injuries. Thus, it seems only logical that the resuscitative operating room of the future would have IR capabilities making it the obvious geographic destination for critically unstable patients, especially those who are exsanguinating. Our trauma programme recently had the opportunity to conceive, design, build, and operationalise a purpose-designed hybrid trauma operating room, designated as the resuscitation with angiographic percutaneous techniques and operative resuscitation (RAPTOR) suite, which we believe to be the first such resource designed primarily to serve the exsanguinating trauma patient. The project was initiated after consultations between the trauma programme and private philanthropists regarding the greatest potential impacts on regional trauma care. The initial capital construction costs were thus privately generated but coincided with a new hospital wing construction allowing the RAPTOR to be purpose-designed for the exsanguinating patient. Many trauma programmes around the world are now starting to navigate the complex process of building new facilities, or else retrofitting existing ones, to address the need for single-site flexible haemorrhage control. This manuscript therefore describes the many considerations in the design and refinement of the physical build, equipment selection, human factors evaluation of new combined treatment paradigms, and the final introduction of a RAPTOR protocol in order that others may learn from our initial efforts.

A booming economy means a bursting trauma system: association between hospital admission for major injury and indicators of economic activity in a large Canadian health region.

BACKGROUND: Injury epidemiology fluctuates with economic activity in many countries. These relationships remain unclear in Canada. METHODS: The annual risk of admission for major injury (Injury Severity Score ≥12) to a high-volume, level-1 Canadian trauma center was compared with indicators of economic activity over a 16-year period using linear regression. RESULTS: An increased risk of injured patient admissions was associated with rising mean gross domestic product (GDP [millions of chained 2002 dollars]) (.36 person increase per 100,000 population/$1,000 increase in GDP; P = .001) and annual gasoline prices (.47 person increase per 100,000 population/cent increase in gasoline price; P = .001). Recreation-related vehicle injuries were also associated with economic affluence. The risk of trauma patient mortality with increasing mean annual GDP (P = .72) and gasoline prices (P = .32) remained unchanged. CONCLUSION: Hospital admissions for major injury, but not trauma patient mortality, were associated with economic activity in a large Canadian health care region.