Trauma Registry Report - rph.health.wa.gov.au

Western Australian State

Trauma Registry Report

2015

Weste r n Aus t ra l i a S ta te Trauma Reg i s t r y Repo r t 2015 3

WA Director of State Trauma Services report

2015 will always be notable in the history of Royal Perth Hospital and the Trauma Service as we achieved a record third consecutive Level 1 Trauma Verification Status, accorded by the Royal Australian College of Surgeons and other partner specialist colleges. The contribution of prehospital care providers and organisations, the interagency co-operation, and the standard of clinical care by the many departments that constitute the RPH Trauma Service were recognised as major pillars of the State Trauma Service. This report summarises the workload and the quality of care provided in 2015. Within this report there are two trauma cohorts that deserve special attention.The 2015 subset of data on Road Trauma is a significant dataset that should not be ignored. There is nothing to celebrate, or anything too alarming in the data on its own, however, in light of the call for action by the World Health Organisation, and our own National Road Safety Strategy, the year 2015 is at the midpoint of both these timelines.In March 2010, the World Health Organisation (WHO) called for a “Decade of Action for Road Safety 2011-2020”. To match this, the Australian National Road Safety Strategy 2011-2020 also committed to a long term vision, through a strategy that would reduce serious injury and deaths on Australian Roads by at least 30 percent.This report, taken on its own, is purely a snapshot of 2015 data from the RPH trauma registry, with some trends over the preceding two years. But juxtaposed against 2011data, this report provides cause for serious concern and a call to national and state authorities for a reassessment of the strategies in place for the next 5 years of this nominated decade.At the start of this strategy, there were 245 serious road trauma admissions (major trauma ISS>15) and 675 minor road trauma admissions. By 2015, our strategies had not delivered any reduction in this number. There were 288 major trauma admissions and 858 minor trauma cases. Unless the implemented strategies start to produce significant results, there is no prospect at all the Western Australia will get anywhere near the National Road Safety Strategy target of “at least 30 percent reduction in deaths and serious injuries”. Setting national targets or being signatories to WHO resolutions should be founded on road safety strategies that are going to work, are implementable, affordable, acceptable to the community, and the responsibility for safe roads should be borne by both the road user and the state. The WHO call for a Decade of Action, by default implies action by governments and regulatory bodies. Our data however suggests that the problem needs to be addressed differently. In 2011, twelve percent of our major trauma admissions were involved in high speed crashes (> 100 kph) in 2015, this figure is now almost 20 percent of all our road crashes. Similarly, the rate of non compliance with seat belts by drivers rose from 7.5% in 2011 to 8.7% in 2015. 11.5% of motorbike riders admitted to RPH failed to use a crash helmet in 2011, and the figure is essentially unchanged at 10.5% in 2015. The “action” required from here onwards is by the road user as well as governments.In 2015, the Australian of the Year (Rosie Batty) brought domestic and family violence into sharp focus and into our living rooms. This was very timely, as we noted through our own work at RPH that the number of these cases that resulted in physical trauma alone, had doubled from sixty eight in 2005 to one hundred and forty three (143) in this report. The demographics and detail behind this will be reported in a subsequent document.The collection and reporting of this detail in injury data is invaluable, and I thank the RPH Trauma Registry and Trauma Service, and the executive who have supported this for more than twenty years.

Sudhakar RaoWA Director of State Trauma Services

Weste r n Aus t ra l i a S ta te Trauma Reg i s t r y Repo r t 20154

Executive Summary

In 2015, RPH managed a total of 713 Major Trauma admissions (ISS >15), an increase of 4.4 per cent from 2014 (683). Overall, however, there were 13.1 per cent less trauma admissions to RPH in 2015, compared to 2014, with a total of 5524 trauma admissions.

Demographic data:• Males continue to dominate trauma admissions with a ratio of two males to one female

(males 65.8 per cent, females 34.2 per cent) (figure 3b).• 58.7 per cent of all trauma in males occurred in the 15 – 44 year age group, compared to

38.3 per cent of trauma in females in the female 15 – 44 year age group (figure 3b).• 17.4 per cent of trauma in males occurred in the 65+ age group, compared to 39.5 per cent

of trauma in females in the female 65+ age group (figure 3b).• 74.9 per cent of all major trauma (ISS >15) occurred in males (figure 3d).• 51.8 per cent of major trauma in males occurred in the 15 – 44 age group, compared to

41 per cent of major trauma in females in the female 15 – 44 age group (figure 3d).• Males outnumbered females in all age groups for major trauma except the 85+ year age group

in 2014, and all age groups in 2015 (figure 3d).

Trauma details:• The majority of traumas were unintentional (86 per cent), followed by personal assaults

(8 per cent) (figure 4a).• 74.6 per cent of minor traumas (ISS<16) occurred in the metropolitan area (table 4a).• 66.3 per cent of major traumas occurred in the metropolitan area (table 4a).• 44.6 per cent of major traumas occurred on the roads (figure 4f). • 49.9 per cent of major traumas were directly attributed to vehicular trauma – Motor Vehicle

Crashes (MVC) and Motor Bike Crashes (MBC). and 29.9 per cent were due to falls (figure 4h).• There was a significant increase in trauma admissions occurring on a school holiday

(21.8 per cent) and a public holiday (7.4 per cent) in 2015, compared to 9.9 per cent and 1.9 per cent respectively in 2014.

Road trauma:For the purposes of the Trauma Registry, road trauma is defined as vehicular-related trauma occurring on a street or highway, including pedestrians and pedal cyclists.• There was a 5.5 per cent increase in major road trauma admissions from 2014 to 2015

(figure 5a).• Postcodes 6000 (CBD) and 6167 (Beckenham, Cannington, East Cannington, Kenwick, Queens

Park and Wattle Grove) were among the top metropolitan locations for road trauma (figure 4d). • The pattern of road trauma in 2015 remains similar to 2014: MVC 57.1 per cent, MBC 25.2

per cent, pedestrians 7.1 per cent and Pedal Cyclists 10.4 per cent (figure 5b).• Seatbelt compliance remains poor with MVC trauma, particularly among rear seat passengers,

with 35.5 per cent being reported as not wearing a seatbelt, compared to 12.8 per cent of drivers (adjusted for not recorded/not applicable). This is a slight deterioration in compliance for drivers (11.7 per cent in 2014) however a significant improvement for rear seat passengers with seatbelt non-compliance 58.6 per cent in 2014 (figure 5c).


• Helmet compliance has deteriorated for MBC trauma, with 10.2 per cent of patients in 2015 reported as not wearing helmets (adjusted for not recorded/not applicable) compared to 8.5 per cent per cent in 2014. (figure 5c).

• Ejected from vehicle would appear to be a marker of increased injury severity, for patients in MVCs, with this category having a median ISS of 19 (Range 6 – 45) (table 5a).

• Non-helmet use was a major contributing factor to increased ISS in MBC trauma, with a median ISS of 11 for this category (Range 1 – 57) (table 5b).

• 58 per cent of all road traumas were reported as travelling between 60 and 100kph (figure 5c).• Higher crash speeds correlate with a higher ISS, with patients in the >100kph and 60 – 100kph

categories having a median ISS of ten (Range 1 – 50) and nine (Range 1 – 57) respectively compared to a median ISS of five (Range 1 – 38) in the <60kph category (table 5d).

Hospital transfers:• 61.3 per cent of major trauma admissions to RPH in 2015 were transfers from other hospitals

(52.4 per cent metropolitan and 46.9 per cent country) (figure 6a).• Metropolitan major trauma transfers were mostly distributed between South Metropolitan Health

Service (SMHS) (53.7 per cent) and North Metropolitan Health Service (NMHS) (41 per cent) (figure 6c).

• Metropolitan major trauma patients spent on average 5.6 hours at NMHS transferring hospitals and 4.9 hours at SMHS facilities (figure 6f).

• Non-metropolitan major trauma patients spent between 4.1 and 9.4 hours on average at their respective rural hospitals, prior to transfer to RPH, compared to between 3.9 and 8.8 hours in 2014 (figure 6e).

RPH arrival:• In 2015, the busiest days of the week for trauma admissions (both major and minor) at RPH were

Sunday (17.7 per cent) and Saturday (16.5 per cent), compared to Tuesday, which was the quietest day with 12.5 per cent of admissions (figure 7a).

• Peak arrival time for major trauma admissions is between 8pm and 10pm (12.7 per cent), and between 2pm and 4pm (12 per cent) for minor trauma admissions. It should be noted, however, that 27.5 per cent of all admissions arrive after hours, between 6pm and 8am (figure 7b).

• The majority of major trauma patients arrived to RPH by road via St John Ambulance (65.5 per cent) and of these, 15.4 per cent required doctor and/or nurse escort (figure 7c/7d).

• 22.9 per cent of all major trauma patients were transferred from the country via Royal Flying Doctor Service (figure 7c).

• There were 68 major trauma patients delivered to RPH by helicopter retrieval teams in 2015, a decrease of 25.2 per cent on 2014 (91 patients) (figure 7c).

RPH initial treatment (major trauma patients):• 77 per cent of major trauma patients received a chest x-ray and 36.6 per cent of patients

received an abdo-pelvic x-ray within 24 hours of arrival to RPH, CT scan was performed on 65 per cent of patients, 15.4 per cent patients were intubated, 39.8 per cent of patients received an Arterial Line, 27 per cent received a Central Vascular Catheter (CVC), FAST was performed on 14.3 per cent of patients (figure 7e).

• Minor trauma patients (ISS <16, excluding deaths) continue to spend the longest time in the Emergency Department (ED), prior to admission to a hospital bed (average 3.9 hours), compared to critical trauma patients (ISS 41-75, excluding deaths) who spent on average two hours in the department. This is a slight change on 2014 with averages of 4.4 hours and 1.8 hours respectively. (figure 7g).


• The majority of major trauma patients were admitted directly from ED to the State Major Trauma Unit (38.3per cent) and a further 20 per cent to a general ward. 14.6 per cent were admitted directly to the Intensive Care Unit (ICU) or High Dependency Area (HDA). However, a further 24.5 per cent of major trauma patients transited via radiology or the operating theatre before ending up in a final general ward destination or the SMTU, or critical care area (ICU) (figure 7h).

RPH admission:• Major trauma patients were predominantly admitted under the trauma team (70.8 per cent)

or Neurosurgery (16.8 per cent) (figure 8b).• 55 per cent of major trauma admissions required surgery (compared to 54.3 per cent in 2014),

with the largest proportion of these procedures being performed on the extremities (37.7 per cent) and abdominal regions (22.1 per cent) (figure 8c).

• 34.2 per cent of major trauma patients were admitted to ICU at some point of their hospital stay, with a median length of stay (LOS) in ICU of four days (excluding deceased) (Range 1 – 121). Median Injury Severity Score (ISS) for these patients was 27 (Range 16 – 75). 18 per cent of all ICU admissions fell into the critical ISS category (ISS 41-75) (table 8a).

Discharge details:• The pattern of distribution for length of stay (LOS) for total trauma admissions (excluding

deceased) has not varied from year to year, with a modal distribution for LOS in the one to three days category (57.1 per cent). Similarly, the modal distribution for LOS for major trauma admissions in 2015 continues to be the same as 2014, in the four to seven days category (30.8 per cent) (figure 9a/9b).

• The average (mean) LOS for: major trauma patients (excluding deceased) is 13 days (compared to 14 days in 2014), major trauma patients (including deceased) 13 days (compared to 13 days in 2014), and minor trauma patients four days (unchanged from 2014) (figure 9c).

• The majority of trauma patients in 2015 (72.4 per cent) were discharged home. 5.6 per cent of patients were transferred to Fiona Stanley Hospital State Rehabilitation Service (SRS) and 7.5 per cent of patients were transferred to non-tertiary rehabilitation. 10.4 per cent of trauma patients were transferred to other metropolitan or non-metropolitan hospitals, or residential institutions, and 2.1 per cent discharged against medical advice. There was a 1.9 per cent mortality rate for all traumas at the RPH Wellington Street Campus (acute care) (figure 9d).

Trauma mortality: • There were a total of 110 deaths in 2015, with Head Injury and Brain Death as the combined

major cause of death (51 per cent) (figure 11a).• 687/713 major traumas (96.3 per cent) were blunt traumas (including burns admissions), with an

11.6 per cent mortality rate in this group. 0.6 per cent of blunt minor traumas died of complications following their injuries (table 11a).

• The mortality rate of 35.1 per cent for critically injured patients (ISS 41-75) was predictably higher than that of minor trauma patients (0.5 per cent) (table 12a).

• Overall, there were 84 major trauma deaths (ISS >15) (11.7 per cent) (table 12a).Mortality rates for major trauma deaths ISS >12 (the new national standard for major trauma) were 9 per cent.


Injury Severity Scores (ISS):• Increased injury severity correlates with a longer length of hospital stay, with patients in the ISS 41

– 75 (excluding deceased) category staying for an average of 28 days at RPH (33 days in 2014), compared to four days for minor trauma patients (figure 11a).

• In 2015, the 15 – 24 year age group formed the largest category of major traumas (33 per cent), closely followed by 25 – 34 years (17.5 per cent). Combined, these two age groups comprised 36.3 per cent of all major traumas (figure 11f).

• The majority of major trauma patients (ISS>15) are triaged to Australasian Triage Scale (ATS) Category one (immediately life-threatening) (41.8 per cent) or Category two (imminently life-threatening) (25.2 per cent). 26.8 per cent were triaged to ATS Category 3. (figure 11g).

• The ISS has often been criticised because of a lack of consideration of the impact of multiple injuries within one body region in its assessment. The New Injury Severity Score (NISS) calculates an injury severity score based on the worst three injuries, regardless of body region. Comparison of ISS with NISS (>15) demonstrates a significantly higher number of ‘major’ traumas admitted to RPH (1160 NISS > 15 compared to 713 ISS >15) and could reasonably be seen as an indication of inpatient workload and resource use.

Burns trauma admissions:• From February 2015, all adult burns patients, except in the context of major multi-trauma, are

now admitted directly to the State Adult Burns Centre at Fiona Stanley Hospital. There were 38 burns injury admissions, with a modal distribution for LOS in the one to three days category for both major and minor burns (figure 12b).

• Fire was the most common cause of burns injuries (32 per cent) followed by hot liquids (21 per cent) (figure 12a).

Spinal trauma admissions:• There were 753 spinal injury admissions, of which 275 (36.5 per cent) were major traumas,

with an ISS >15. This represents an overall 7.8 per cent increase in major trauma patients with spinal injuries from 2014 to 2015, with a corresponding 4.1 per cent increase in patients with neurological deficit (73 in 2014 and 76 in 2015) (table 13a).

• Vehicular-related trauma (MVC/MBC/pedal cyclists/pedestrians) was the main cause for spinal cord injuries (47.4 per cent), followed by falls (32.9 per cent) (figure 13a).

Head injury admissions:• There were 558 head injury admissions (Abbreviated Injury Scale score >2). Of these, 328 (58.8

per cent) were major traumas with an ISS > 15 (table 14a).• The main cause of trauma for head injury patients was falls (45.1 per cent), followed by vehicular-

related trauma (38.7 per cent). The next most significant group was ’struck by/struck object’ (11 per cent) (figure 14a).

Splenic injury admissions:• There were 105 splenic injury admissions. Of these, 76 (72.4 per cent) were major traumas with

an ISS > 15 (table 15a).• The main cause of trauma for splenic injury patients was vehicular-related trauma (66.7 per cent),

followed by falls (19 per cent) (figure 15a).


Renal injury admissions:• There were 55 renal injury admissions. Of these, 43 (78.2 per cent) were major traumas with an

ISS > 15 (table 15d).• The main cause of trauma for renal injury patients was vehicular-related trauma (69.1 per cent),

followed by falls (14.5 per cent) (figure 15b).

Hepatic injury admissions:• There were 102 hepatic injury admissions. Of these, 68 (66.7 per cent) were major traumas with

an ISS > 15 (table 15f).• The main cause of trauma for hepatic injury patients was vehicular-related trauma (71.6 per cent),

followed by falls (14.7 per cent) (figure 15c).

Alcohol and drug-related trauma admissions:• 19.8 per cent of all trauma admissions had documented alcohol and/or drug use in the 12 hours

preceding their trauma event.• For the majority of these patients (69.1 per cent), the intent of the trauma was unintentional.

However, 24.4 per cent of alcohol-related events were documented as personal assault and/or domestic violence and 5 per cent were self- harm (figure 16a).

• The main cause of trauma for alcohol and/or drug affected patients was vehicular-related trauma (31.5 per cent) followed by falls (26.6 per cent) and struck/struck by object (26.1 per cent) (figure 16c).

RPH Trauma Service:• Since its inception in August 1994, the Trauma Registry at RPH has seen an overall increase of

221 per cent in annual major trauma admissions (ISS >15), and an increase of 99 per cent in minor trauma admissions. The overall increase in annual total trauma admissions has been 109 per cent (figure 17a/17b).


Royal Perth Hospital Trauma CommitteeDirector, Trauma Services:Mr Sudhakar Rao Consultant, Department of General SurgeryCommittee Members:Ms Maxine Burrell Trauma Program Manager, Trauma ServicesAssoc. Professor John Buchanan Head of Department Allied HealthDr Sacha Schweikert Consultant, Intensive Care UnitDr Stephen Dunjey Consultant, Emergency DepartmentMr Stephen Honeybul Consultant NeurosurgeonMs Carmel McCormack Nurse Coordinator, Theatres (notification only)Dr John Martyr Consultant, Department of AnaesthesiaMr Alan Prosser Consultant, Orthopaedic Surgery DepartmentDr Swithin Song Deputy Head of Imaging ServicesMs Sheryl Jonescu Trauma Case ManagerClinical Nurse Specialist Emergency DepartmentMs Kathy Young CNS, State Major Trauma UnitDr Amyn Pardhan Trauma FellowDr Sana Nasim Trauma Fellow

Trauma Registry Ms Jenni Leslie Research NurseMs Jan Neilson Research NurseMs Claire Forsdyke Research Nurse Ms Sharon Kay Research NurseMs Bavany Shivakumar Administrative Assistant

Injury PreventionMs Michaela Copeland Injury Prevention Research NurseMs Lilian Camilleri Administrative AssistantMs Kellie Christie Project Officer

State Trauma RegistryMs Annette MacTaggart Research NurseMs Natalie Kruger Research NurseMs Arpana Pudaruth/Ms Angela Chan Clerical Assistant


Trauma Service

Mr Sudhakar Rao Trauma SurgeonMr René Zellweger Trauma SurgeonDr Dieter Weber Trauma SurgeonDr Amyn Pardhan/Sana Nasim Trauma FellowMs Sheryl Jonescu Trauma Case ManagerMs Kathy Young CNS, SMTUMs Maxine Burrell Trauma Program ManagerMarcel Palencia Trauma Clinical PsychologistsMs Fiona Coll Senior Trauma PhysiotherapistMs Diane Atkinson/ Ms Laura Wolters Senior Trauma Social WorkerMs Fiona Khamhing/Joe Pagel Senior Trauma Occupational TherapistsMs Mary Hunt Trauma Speech PathologistMs Jacqui Tuck Trauma DieticianBo Kim Trauma PharmacistMs Angela Chan Clerical Assistant


Table of contents

Page Number 1. Trauma registry database 12

2. Data collection and quality 13

3. Demographic data 15

4. Trauma details 19

5. Road trauma 24

6. Primary hospital treatment 27

7. Royal Perth Hospital Emergency Department 30

8. Royal Perth Hospital treatment 34

9. Discharge details 37

10. Patient outcomes 39

11. Injury severity scores 41

12. Burns admissions 45

13. Spinal injury patients 46

14. Head injury patients 47

15. Abdominal solid organ injury patients 48

16. Alcohol and drug-related trauma 51

17. The Trauma Service at Royal Perth Hospital 53

18. Education and research 56

19. Injury prevention 60

20. Appendices 61 Appendix i Monthly quality improvement database queries

Appendix ii Health regions of Western Australia Appendix iii Injury Severity Score and Abbreviated Injury Scale Appendix iv Trauma clinical indicators and audits Appendix v Data usage 2014 Appendix vi Royal Perth Hospital Trauma Team Activation Guidelines Appendix vii Abbreviated Injury Scale (AIS) and Organ Injury Scale (OIS) codes for solid organ injury

All the data contained in this report has been obtained from the Royal Perth Hospital Trauma Registry and therefore should not be reproduced, quoted or copied without reference to the source. Any queries regarding the data in this report, or any requests for further information, should be directed to the Trauma Registry on 9224 2551.

12 Weste r n Aus t ra l i a S ta te Trauma Reg i s t r y Repo r t 2015

1. Trauma registry database

1.1 Trauma registry databaseTrauma registry databaseThe Trauma Registry has been collecting data on trauma patients since August 1994, and the database now contains over 93,000 trauma admissions. This data is available on application for research or audit use and has been extensively utilised in the presentation of Trauma Grand Rounds and various research projects (Appendix vii). The Trauma Registry also provides data for the strategic planning of trauma services, as well as for trauma-related clinical indicators (Appendix v). Data is also provided annually to the Department of Health, Western Australian Data Linkage Unit.The web-based SQL Trauma Registry database allows direct interface with other hospital information systems (The Open Patient Administration System, Emergency Department Information System, Theatre Management System), enabling automatic download of verified data such as demographics and surgical procedures. Data quality is augmented due to the use of improved validation rules and mandatory fields.

13Weste r n Aus t ra l i a S ta te Trauma Reg i s t r y Repo r t 2015

2. Data collection and quality

2.2 Definition of registry populationFor the purposes of the registry, Trauma is defined as “an injury or wound resulting from an external force” (Miller and Keane, 1983).The criteria for inclusion into the registry are:• All trauma patients who present to RPH for treatment within seven days of their date of trauma

and who were hospitalised for greater than 24 hours at RPH.• All trauma-related deaths at RPH regardless of hospital length of stay.Patients who have suffered the effects of poisoning and drug overdose are excluded from the registry.The registry population is divided into major and minor trauma admissions according to the Injury Severity Score (ISS) (see Appendix iii). Major trauma admissions are those patients who have an ISS of greater than 15. An extensive dataset is collected on these patients, from the time of trauma to discharge from RPH, including pre-RPH treatment. Minor trauma admissions are those patients who meet the registry inclusion criteria and have an ISS of less than 16. A limited dataset is collected on these patients.Four research nurses collect data on admissions meeting the registry inclusion criteria. Patients for inclusion are identified through a custom-designed Microsoft Access database. This database was designed by the Business Performance Unit at RPH and contains daily updates of all ED presentations and hospital admissions for the previous 24 hours. The patient’s medical record is the main source of data for the registry, in conjunction with the hospital’s computerised Patient Administration System (TOPAS), ED Information System (EDIS), iSoft Clinical Manager, The Electronic Discharge Summary (TEDS), The Picture Archiving Clinical System (PACS) and the Theatre Management System (TMS) providing supplementary data sources. Data primarily collected on a hard-copy data collection form and then entered onto a Web-based, SQL database, although some major traumas (ISS >15) are collected electronically, directly onto the database using a laptop.The Abbreviated Injury Scale (AIS) 2005 (2008 Update) is currently in use.Major trauma admissions are reviewed during their stay in hospital on a regular basis and details of their condition, surgical management, complications and injuries at discharge are recorded on the data sheets. Patients that are transferred to the state rehabilitation centre at Royal Perth Rehabilitation Hospital (RPRH) are also followed throughout the course of their stay.

2.3 Registry data quality improvement In-line with the commitment of trauma registry research, staff are to maintain the integrity of information held in the registry database, a series of data checks are conducted. These QI activities check for common injury scoring errors, null data fields, and discrepancies between data collection forms and data entry. As queries are now conducted by individual staff, and during the orientation of new staff members, data checks can now be run frequently to quickly identify problem data entry areas, so that education can be appropriately targeted. Similarly data checks related to injury scoring issues are used to target education for new research staff. Ad-hoc Quality Improvement (QI) queries are also performed when specific problem data entry areas are identified and, if necessary these are incorporated into the quarterly checks. A list of the QIs that are currently carried out are listed in (Appendix i).


During 2013, a new query tool was developed, which enables individual staff to monitor their own data entry and perform their own data checks. With the emphasis on individual responsibility for checking the quality of their data, a new system was developed to monitor the compliance of staff with this new query tool. Each quarter, the query tool is run for the preceding three months for each staff member to determine if they have been identifying and correcting their own errors. Staff are then notified of any errors that have been identified in this compliance check, and are then given a further two weeks to correct these errors. A further compliance check is then undertaken to determine if the staff member has completed this. For those staff members found to be non-compliant, individual education is given. In line with this new system, we will now be reporting on the compliance rate of staff with the QI system, rather than an overall error rate. Compliancy rates for 2015 have ranged from 95 per cent to 100 per cent. Several staff members have consistently had a compliancy rate of 100 per cent.

Figure 1: Staff compliance with QI by quarter

*Did not have any data complete patients for audit for Oct - Dec quarter.


3. Demographic Data

3.1 Total trauma admissions

There has been an overall decrease of 13.1 per cent in total trauma admissions to RPH from 2014 to 2015.

Figure 3a: Total trauma admissions

2013 2014 2015Total trauma admissions: 6447 6361 5524Average monthly admissions: 537 530 460Range: 452 – 587 498 – 572 405 – 576


3.2 Age and sex distribution (total trauma admissions)

Male: 3634 65.8 per cent of total admissionsFemale: 1890 34.2 per cent of total admissions

Figure 3b: Age and sex distribution of total


3.3 Major trauma admissions

The trauma population is divided into major (patients with an ISS > 15), and minor trauma. In 2015, major trauma patients comprised 12.9 per cent of the total trauma admissions. This is slightly higher than 2014 (10.7 per cent) and is probably reflective of the opening of the new Fiona Stanley Hospital in February 2015, and the more appropriate re-distribution of minor trauma admissions. Major trauma patients generally spend longer in hospital and often require intensive care treatment, as well as extensive rehabilitation. Thus, although forming a small part of the total trauma admissions, it is the major trauma patients on whom the registry collects the majority of clinical data.

2013 2014 2015Total trauma admissions: 623 683 713Average monthly admissions: 52 57 59Range: 43 – 66 46 – 65 44 – 75

There has been a 4.4 per cent increase in major traumas (ISS>15) from 2014 to 2015.

Figure 3c: Major trauma admissions


3.4 Age and sex distribution of major trauma admissions

2014 2015Male: 515 (75.4 per cent) 534 (74.9 per cent)Female: 168 (24.6 per cent) 179 (25.1 per cent)

Figure 3d: Age and sex distribution of major trauma admissions


4. Trauma details

4.1 Intent of trauma (total trauma admissions)

Figure 4a: Intent of trauma

4. 2 Trauma incidents by holiday code (total trauma admissions)

Figure 4b: Mean daily trauma incidents by type of day


4.3 Location of tauma incident

Table 4a: Location of trauma incident

Country per cent Change Metro per cent ChangeMajor2013 215 (34.5 per cent) 2.4 per cent 398 (63.9 per cent) 19.1 per cent2014 256 (37.5 per cent) 19 per cent 424 (62.1 per cent) 6 per cent2015 238 (33.4 per cent) -7 per cent 473 (66.3 per cent) 11.5 per centMinor2013 1474 (25.3 per cent) 5.7 per cent 4243 (72.8 per cent) 6.5 per cent2014 1505 (26.5 per cent) 2.1 per cent 4139 (72.9 per cent) -2.4 per cent2015 1190 (24.7 per cent) -20.9 per cent 3590 (74.6 per cent) -13.3 per cent

*Unknown/International/Interstate admissions have been excluded from this table.

Figure 4c: Location of trauma incident (major trauma admissions)

* Unknown/International/Interstate or unknown admissions have been excluded from this graph.


Figure 4d: Top 10 Metropolitan road trauma locations 2015 (total road trauma) by postcode

Post Code

Suburbs Number of Patients (previous year)

6000 CBD 34 (54)

6107 BeckenhamCannington

East CanningtonKenwick

Queens Park Wattle Grove

21 (30)

6056 BaskervilleBellevueBoyaGreenmountHelena Valley

Herne Hill Jane Brook Koongamia Middle Swan

Midland Midvale Millendon Red Hill

Stratton Swan View Viveash Woodbridge

31 (29)

6062 EmbletonMorley Noranda

22 (24)

6069 Aveley BelhusBrigadoon

EllenbrookThe VinesUpper Swan

22 (24)

6003 HighgateNorthbridge

16 (2)

6050 CoolbiniaMenoraMt Lawley

21 (14)

6053 Bayswater 17 (18)

6076 Bickley Carmel Gooseberry Hill

Hacketts GullyPickeringPaulls ValleyPiesse Brook

KalamundaLesmurdieReservoirWalliston

16 (11)

6112 ArmadaleForrestdale Harrisdale

Mount Nasura Mount RichonPiara Waters

Seville Grove Wungong

23 (15)


4.4 Site of trauma incident

Figure 4e: Site of trauma incident (total trauma admissions)

Figure 4f: Site of trauma incident (major trauma admissions)


4.5 Cause of trauma

Figure 4g: Cause of trauma (total trauma admissions)

Figure 4h: Cause of trauma (major trauma admissions)


5. Road Trauma

For the purposes of this report, Road Trauma is defined as vehicular-related trauma occurring on a street or highway.

5.1 AdmissionsFigure 5a: Total road trauma admissions

Figure 5b: Total road trauma admissions by category


5.2 Safety devicesFigure 5c: Safety devices for road trauma 2015

MVC n= 655 minus:• Five back passenger trauma patients no safety devices recorded, nine back passenger trauma patients

were not applicable (car surfing/jumped from moving vehicle/bus passenger).• Eighteen MVC driver trauma patients no safety device recorded.• Six front seat passenger trauma patients no safety devices recorded, four front seat passenger trauma

patients. Seatbelt not applicable (jumped from moving vehicle/bus passenger).

MBA n= 289 minus:• 13 No safety devices recorded.Pedal cyclists n = 120 minus:• 12 No safety devices recorded.


5.3 Road trauma details (total trauma admissions) Table 5a: Factors in motor vehicle and motor bike crashes affecting ISS - 2015

Factor Number of MVCs

Per cent of Road MVCs

Median ISS (Range)

No risk factors* 216/527 41 per cent 5 (1 – 50)Rollovers 196/655 29.9 per cent 9 (1 – 75)Death in same accident 42/655 6.4 per cent 14 (1 – 50)Speed > 100 km/h** 109/553 19.7 per cent 10 (1 – 50)No seatbelt*** 71/613 11.6 per cent 13 (1 – 45)Trapped In vehicle 192/655 29.3 per cent 14 (1 – 75)Ejected from vehicle 22/655 3.3 per cent 19 (6 – 45)

Denominator: MVA n= 655 minus:• *128 patients’ speed and seatbelt not recorded or not applicable.• **102 patients’ speed not recorded.• ***42 patients’ seatbelts not recorded or not applicable.

Factor Number of MBCs

Per cent of Road MBCs

Median ISS (Range)

No risk factors* 207/248 83.5 per cent 9 (1 – 50)No helmet** 29/276 10.5 per cent 11 (1 – 57)Speed > 100 km/h*** 22/257 8.6 per cent 9 (1 – 43)

Denominator: MBA n= 289 minus:• *41 patients’ speed and helmet not recorded.• **13 patients’ helmets not recorded.• ***32 patients’ speed not recorded.

Figure 5d: Speed for all road trauma (MVCs and MBCs) 2015

*134 MVC/MBC trauma patients where speed is not recorded have been omitted from this chart

Table 5b Effect of speed on injury severity levels

Speed Median ISS< 60 km/h 5 (1 – 38)60 - 100 km/h 9 (1 – 57)> 100 km/h 10 (1 – 50)


6. Primary hospital treatment

6.1 Treating hospitalsSee Appendix ii for a list of hospitals within the corresponding health regions.

Figure 6a: Transfers from regional health regions (major trauma admissions ISS >15).

Figure 6b: Transfers from regional health regions (minor trauma admissions ISS <16).

Figure 6c: Transfers from metropolitan area health services (major trauma ISS >15).


Figure 6d: Transfers from metropolitan area health services hospitals (minor trauma ISS <16).

6.2 Time spent pre RPH according to health regionsFigure 6e: Average number of hours spent in hospitals within regional health regions

Figure 6f: Average number of hours spent in metropolitan health regions

*Patients who spent more than 24 hours at the referring health regions have been excluded from these graphs.


6.3 Pre RPH interventions (major trauma admissions)Figure 6g: Non-metropolitan hospital primary interventions (count of patients)

Figure 6h: Metropolitan hospital interventions (count of patients)


7. Royal Perth Hospital Emergency Department

7.1 AdmissionsFigure 7a: Annual trauma admissions by day of week 2015

Figure 7b: Annual trauma admissions by time of day


7. 2 Mode of arrival (major trauma admissions)Figure 7c: Mode of arrival to Royal Perth Hospital

Figure 7d: Escort to Royal Perth Hospital 2015


7.3 Interventions (major trauma admissions)Figure 7e: Interventions within first 24 hours of arrival to RPH (count of patients)

7. 4 Time spent in the Emergency DepartmentFigure 7f: Average time in emergency department according to ISS (including deaths)

Figure 7g: Average time in emergency department according to ISS (excluding deaths)


7. 5 Dispatch from Emergency DepartmentFigure 7h: Destination from Emergency Department (major trauma admissions)

RADIOLOGY 126

THEATRES 49

SMTU (High Acuity) 149

DEATH 16

GEnERAL wARD143

ICU 104

OBS ward 1

BURnS UnIT1

SMTU 124

THEATRES 29

ICU 43


SMTU12

GEnERAL wARD 3

GEnERAL wARD5

ICU 24

RADIOLOGY 5

DEATH 3


SMTU2

ICU 1

GEnERAL wARD 1

ICU 3

THEATRES 1

DEATH1


ICU 25


8. Royal Perth Hospital treatment

8. 1 Admitting teamsFigure 8a: Admitting specialty (total trauma admissions) 2015

Figure 8b: Admitting specialty (major trauma admissions)


8.2 Operations at Royal Perth Hospital (major trauma admissions)

2012 2013 2014 2015Total trauma admissions: 552 623 683 713Patients requiring operations: 320 339 371 392Percentage: 57.9 per cent 54.4 per cent 54.3 per cent 55 per cent

Figure 8c: Operations performed by body region at Royal Perth Hospital (major trauma ISS > 15).


8.3 Intensive care admissionsTable 8a: Major trauma patients (ISS >15) to Intensive Care Unit at any time during trauma admission at Royal Perth Hospital

Major trauma admissions

Number of ICU admissions and per cent of major trauma admissions

Median ISS (range) of ICU admissions

Proportion of ICU admissions that are critical (ISS 41-75)

All ISS > 15Average LOS ICU (Days*)

Median LOS (Days*)(Range)

ISS >15 (Ex-deaths)Average LOS ICU (Days*)

Median LOS (Ex-deaths) (Days*)(Range)

2001 330 155 (46.9) 26 (16 – 75) 16.1 per cent 7.58 4 (1 – 37) 7.75 4 (1 – 32)2002 372 163 (43.8) 26 (16 – 75) 15.3 per cent 8.73 4 (1 – 56) 8.70 5 (1 – 50)

2003 347 140 (40.3) 27 (16 – 75) 25 per cent 7.74 4 (1 – 51) 8.05 5 (1 – 33)

2004 422 160 (37.9) 26 (16 – 75) 21.2 per cent 8.59 4 (1 – 56) 8.94 5 (1 – 56)

2005 412 167 (40.5) 29 (16 – 75) 17.9 per cent 7.50 5 (1 – 48) 8.23 6 (1 – 48)

2006 517 204 (39.4) 27 (16 – 75) 17.6 per cent 7.52 5 (1 – 48) 7.48 5 (1 – 31)

2007 391 186 (47.5) 26 (16 – 75) 10.2 per cent 7.40 5 (1 – 34) 8.10 7 (1 – 34)

2008 446 206 (46.2) 25 (16 – 75) 8.2 per cent 7.84 5 (1 – 56) 8.62 6 (1 – 56)

2009 473 211 (44.6) 26 (16 – 75) 13.7 per cent 10.34 7 (1 – 100) 11.01 8 (1 – 100)

2010 528 214 (40.5) 26 (16 – 75) 7.9 per cent 7.49 5 (1 - 59) 8.17 6 (1 – 59)

2011 552 219 (39.7) 26 (16 – 75) 15.5 per cent 7.51 5 (1 - 74) 8.20 5 (1 – 74)

2012 552 213 (38.6) 26 (16 – 75) 14.1 per cent 6.32 4 (1 – 28) 7.07 5 (1 – 28)

2013 623 249 (40) 26 (16 – 75) 14.1 per cent 7.2 4 (1 - 69) 8.14 5.5 (1 – 69)

2014 683 226 (33.1) 27 (16 – 75) 18.1 per cent 6.55 4 (1 – 83) 7.03 5 (1 – 83)

2015 713 244 (34.2) 27 (16 – 75) 18 per cent 6.65 4 (1 – 121) 7.15 4 (1 – 121)

* Includes part of day

Figure 8d: Percentage of major trauma admissions to Intensive Care vs ICU length of stay


9. Discharge details

9. 1 Length of stay at Royal Perth HospitalFigure 9a: Number of days in hospital (excluding deaths) total trauma admissions

Figure 9b: Number of days in hospital (excluding deaths) major trauma admissions

Figure 9c: Average length of stay


9.2 Discharge destinationFigure 9d: Discharge destination from Royal Perth Hospital (total trauma)

Transfers:

*Tertiary rehabilitation was relocated from Royal Perth Rehabilitation Hospital (RPRH) to the Fiona Stanley State Rehabilitation Centre (SRC) in October 2014. 141 patients were transferred to SRC post this date in 2014.


10. Patient outcomes

10.1 Trauma mortalityFigure 10a: Cause of death (total traumas) 2015

N = 110N.B Cause of death is subject to change following hospital Trauma Mortality Audit.

Table 10a: Mortality rate - blunt vs. penetrating Injuries

MAJOR ISS > 15 MINOR ISS < 16

Year Type of Trauma

Total Deceased Per centMortality

Total Deceased Per centMortality

2013 Blunt 605 78 12.9 per cent

4770 49 1 per cent

Penetrating 18 4 22.2 per cent

1053 1 0.09 per cent

2014 Blunt 653 83 12.7 per cent

4656 37 0.8 per cent

Penetrating 30 3 10 per cent 1023 1 0.1 per cent

2015 Blunt 687 80 11.6 per cent

3962 25 0.6 per cent

Penetrating 26 4 15.4 per cent

848 1 0.1 per cent


Table 10b: Mortality Rate within each ISS category

Injury Severity Score (ISS) Category

Year 1 – 15 per cent 16 – 24 per cent 25 – 40 per cent 41 – 75 per cent

2005 44/3409 1.3 per cent 8/207 3.9 per cent 18/167 10.8 per cent 14/38 36.8 per cent


2007 38/4099 0.9 per cent 11/186 5.9 per cent 34/179 19 per cent 11/26 42.3 per cent









• There were 110 deaths in 2015 (two per cent of total trauma admissions).• There were 84 major trauma deaths (ISS > 15) (11.7 per cent of major trauma admissions).• *There were 86 trauma deaths ISS > 12 (nine per cent of all patients ISS >12).

*Since the adoption of ASI 2005(2008 update), many Australian Major Trauma Centres have redefined Major Trauma as ISS >12. This is also the cut off ISS for major trauma for the Australian Trauma Registry.


11. Injury severity scores

Figure 11a: ISS vs. average length of stay in Royal Perth Hospital (excluding deaths)

Figure 11b: Average length of stay for ISS Group 41 – 75

Figure 11c: Average length of stay for ISS Group 25 – 40

Figure 11d: Average length of stay for ISS Group 16 – 24


Figure 11e: Minor trauma admissions (ISS < 16) by age

Figure 11f: Major trauma admissions (ISS > 15) by age 2015

Figure 11g: Major trauma admissions (ISS > 15) by triage category


The Injury Severity Score (ISS) has often been criticised on account of the lack of consideration of the impact of multiple injuries within one body region in its assessment.In the following example of the ISS scoring process, the individual has significant injuries in three regions – the head, the abdominal region, and an extremity (lower leg). The square of the three most severe scores (subdural haematoma in the head region) in each body region are applied, by rule. The ISS score adds up to 41.

Injury Severity ScoreExample AIS ScoreSmall subdural haematoma 4Parietal lobe swelling 3Major liver laceration 4Upper tibial fracture (displaced) 3

ISS = 42 + 42 + 32 = 41

A revised version of the ISS has been developed to address the issue of multiple injuries in the same body region. The New Injury Severity Score (NISS) is very similar to the ISS. However, it scores the three most severe AIS scores regardless of their body region location. Thus, multiple injuries within a body region can be considered in the NISS.

ISS vs. NISS - an Example AIS Score RegionMultiple abrasions 1 ExternalDeep laceration tongue 2 Face Subarachnoid hemorrhage 3 Head/NeckMajor kidney laceration 4 AbdomenMajor liver laceration 4 Abdomen

ISS = (4)2 + (3)2 + (2)2 = 29NISS = (4)2 + (4)2 + (3)2 = 41

In this example, an individual has five significant injuries. The NISS differs from the ISS in that it includes both injuries in the abdomen (liver and kidney lacerations) because their levels of severity exceed those of the injuries in the other regions. Baker, 1997

A comparison of NISS (>15) with ISS (>15) is shown in Figure 11h.


Figure 11h: Comparison of ISS with NISS (Score > 15)

The NISS score (>15) demonstrates a significantly higher number of ‘major’ traumas admitted to RPH and could reasonably be seen as an indication of inpatient workload and resource use.

Table 11b: Number of patients according to body region and AIS severity.

Body region Count of patients per body region and AIS severity

AIS 1 AIS 2 AIS 3 AIS 4 AIS 5 AIS 6

Head/neck 374 1120 1137 261 191 4

Face 764 564 16 1

Chest 305 1197 759 135 47

Abdomen 80 790 192 94 11

Extremities 1881 3399 826 34 13

Skin 7541 127 8 1 4 2

Abbreviated Injury Scale (AIS) legend:AIS severity score Description1 Minor2 Moderate3 Serious4 Severe5 Critical6 Maximal (generally untreatable)


12. Burns admissions

Figure 12a: Mechanism of trauma for total burns injuries admissions 2015

Figure 12b: Length of stay for total burns admissions 2015

Table 12a: Summary of burns injury admissions

Year Minor admissions Major admissions Total admissions2013 360 30 3902014 326 22 3482015* 29 9 38

From February 2015, all adult burns patients, except in the context of major multi-trauma, are now admitted directly to the State Adult Burns Centre at Fiona Stanley Hospital


13. Spinal injury patients

Figure 13a: Cause of trauma for spinal cord injury patients**

Table 13a: Summary of spinal injury admissions*

Year Minor admissions(iss<16)

Major admissions(iss>15)

Neuro deficit **

Total admissions

Per cent change

2010 309 183 39 4922011 316 206 47 522 6.1 per cent2012 367 200 46 567 8.6 per cent2013 453 214 52 667 17.6 per cent2014 463 255 73 718 7.6 per cent2015 478 275 76 753 4.9 per cent

* Injuries with an AIS score >1** This figure denotes those patients diagnosed with either incomplete or complete cord syndrome (spinal

cord injury) as a result of cord contusion or laceration, documented by x-ray, CT scan, MRI or autopsy. Following the significant increase in spinal cord injury from 2013 to 2014 (40.1 per cent), there has been a further 4.1 per cent increase from 2014 to 2015.

Table 13b: Count of spinal injuries according to Abbreviated Injury Scale (AIS).

Year AIS 2 AIS 3 AIS 4 AIS 5 AIS 62010 1005 174 13 21 12011 1092 203 20 19 42012 1183 241 21 14 12013 1320 224 28 14 42014 1398 271 43 17 32015 1553 319 44 20 1


14. Head injury patients

14.1 Head injury patientsFigure 14a: Primary cause of trauma for head injury patients ISS >15

Table 14a: Summary of head injury admissions* to Royal Perth Hospital

Year Minor Admissions(Iss <16)

Major Admissions(Iss >15)

Minor Admissions To Tertiary Rehabilitation

Major Admissions To Tertiary Rehabilitation

Total Admissions

Per CentIncrease/Decrease

2010 165 283 6 39 448

2011 149 289 11 60 438 -2.2

2012 162 307 22 61 469 7.1

2013 203 309 16 54 512 9.2

2014 230 333 8 76 563 9.9

2015 230 328 22 92 558 -0.9

* AIS > 2

Table 14b: Count of head injuries* according to Abbreviated Injury Scale (AIS)

Year AIS 3 AIS 4 AIS 5 AIS 62010 778 182 133 12011 698 180 153 12012 772 216 167 22013 878 223 163 02014 1017 217 187 42015 969 219 167 3

* AIS > 2


15. Abdominal solid organ injury patients

15.1 Splenic injuryFigure 15a: Primary cause of trauma for splenic injury patients

Table 15a: Summary of splenic injury admissions to Royal Perth Hospital

Year Minor Admissions(ISS <16)

Major Admissions (ISS >15)

Total Admissions


2010 13 43 56 -2011 13 49 62 11.5 per cent2012 18 50 68 6.4 per cent2013 28 51 79 14.7 per cent2014 29 63 92 17.9 per cent2015 27 76 105 14.1 per cent

Table 15b: Count of splenic injuries according to Abbreviated Injury Scale (AIS) and Organ Injury Scale (OIS).

Year AIS 2 (OIS I,II)

AIS 3(OIS III)

AIS 4 (OIS IV)

AIS 5(OIS V)

2010 32 12 10 22011 34 12 16 12012 42 10 14 22013 37 15 23 42014 48 23 18 32015 54 21 22 8


Table 15c: Management options for splenic injuries 2015.

AIS Conservative Management

Splenic Embolisation

Splenorrhaphy Total Splenectomy

2 51 2 13 14 6 1 14 12 7 35 4 5

*Patients may undergo more than one intervention.

Asplenic patients have a lifelong increased risk of overwhelming infections, particularly with encapsulated bacteria such as Streptococcus pneumoniae, Neisseria meningitidis and Haemophilus influenzae type B. Post-splenectomy patients are usually immunised against these three key bacteria prior to leaving hospital, with a follow-up review of immunisation status to consider re-immunisation for the pneumococcal and meningococcal vaccine agent after five years.See Appendix xii for detailed list of AIS codes and descriptions for splenic injury.

15.2 Renal injuryFigure 15b: Primary cause of trauma for renal injury patients

Table 15d: Summary of renal injury admissions to Royal Perth Hospital



Total Admissions


2010 16 33 49 -2011 14 28 42 - 14.3 per cent2012 20 35 55 30.9 per cent2013 24 32 56 1.8 per cent2014 23 35 58 3.6 per cent2015 12 43 55 -5.1 per cent


Table 15e: Count of renal injuries according to Abbreviated Injury Scale (AIS) and Organ Injury Scale (OIS)


AIS 3(OIS III)

AIS 4 (OIS IV)

AIS 5(OIS V)

2010 39 6 9 02011 32 8 4 02012 38 10 7 22013 36 8 11 22014 41 13 8 12015 33 10 17 0

See Appendix xii for detailed list of AIS codes and descriptions for renal injury.

15.3 Hepatic injuryFigure 15c: Primary cause of trauma for hepatic injury patients

Table 15f: Summary of hepatic injury admissions to Royal Perth Hospital



Total Admissions


2010 19 52 71 -2011 23 53 76 7 per cent2012 20 42 62 -18.4 per cent2013 16 49 65 4.8 per cent2014 24 61 85 30.7 per cent2015 34 68 102 20 per cent


Table 15g: Count of hepatic injuries according to Abbreviated Injury Scale (AIS) and Organ Injury Scale (OIS)


AIS 3(OIS III)

AIS 4 (OIS IV)

AIS 5(OIS V)

2010 61 11 4 02011 53 14 12 12012 44 12 7 02013 43 12 9 12014 59 16 8 42015 70 21 13 1

See Appendix xii for detailed list of AIS codes and descriptions for hepatic injury.


16. Alcohol and drug-related trauma

Figure 16a: Age/sex distribution of alcohol and drug-related trauma.

Figure 16b: Intent for alcohol and drug-related trauma


Figure 16c: Cause of trauma for alcohol and drug-related trauma

There is currently no mandatory alcohol and drug testing in Western Australia. Therefore, unless clinically indicated, alcohol and drug use is largely self-reported and therefore likely to be understated within the trauma registry data.


17. The Trauma Service at Royal Perth Hospital

Figure 17a: Major trauma admissions 2007 – 2015

Figure 17b: Minor trauma admissions (ISS <16) 2007 – 2015

Since its inception in August 1994, the trauma registry at Royal Perth Hospital has seen an overall increase of 221 per cent in major trauma admissions (Injury Severity Score > 15), and an increase of 99 per cent in minor trauma admissions (Injury Severity Score <16). The overall increase in trauma admissions to Royal Perth Hospital has been 109 per cent.Following Royal Perth Hospital’s designation in 2004 as the WA State Adult Major Trauma Service, key developments in infrastructure and trauma personnel appointments have been established, as part of Royal Perth Hospital’s commitment to the quality outcome of trauma patients. Trauma patients may be admitted under a combination of teams depending on the nature of their injuries. The introduction of a designated ‘trauma’ sub specialty for multiple injured patients facilitates a more coordinated approach to the multi-disciplinary problems faced by these patients.The purpose-built State Major Trauma Unit (SMTU) was opened in February 2008. The transitional concept of this unit allows the consolidation of complex, multi-trauma patients into a single, dedicated area that facilitates improved coordination and management of these multi-specialty patients during the acute phase of their trauma care. Key appointments in medical, nursing and Allied Health staff make up the components of the multidisciplinary trauma service:


Director Trauma Services/Trauma SurgeonResponsible for the overall planning, directing and implementing of trauma systems at Royal Perth Hospital, to ensure optimum delivery of care to trauma patients.

Trauma surgeons (1.2 FTE)This position complements the existing Trauma Director position and forms part of the Trauma on-call roster, ensuring 24-hour consultant cover seven days a week. Involvement in quality improvement, education and research activities is also part of the scope for this position.

Trauma Fellow This position is responsible for the day to day teaching and supervision of the junior medical staff.

Trauma registrars (4 FTE)This role is responsible for the 24/7 coordination of trauma patient care and plays a major role in the initial resuscitation phase, planning patient care and liaising with other surgical specialties. Together with the trauma residents, the Trauma Registrar responds to Emergency Department trauma calls, performs the tertiary surveys and monitor patients’ progress and outcome. The registrars support other roles within RPH by teaching, supervising, researching and providing feedback.

Trauma resident (4FTE)In-house 24/7 resident cover on the State Major Trauma Unit is provided by residents. Together with the trauma team, and in liaison with the relevant admitting specialty, the SMTU trauma RMO is responsible for the day-to-day management and coordination of trauma patient care, with particular emphasis on the high acuity patients within the unit. Tertiary surveys are performed on all trauma patients who meet trauma activation criteria and are the joint responsibility of the SMTU RMO and the admitting specialty RMO.

Trauma InternThis post provides interns with experience of managing a broad range of primarily orthopaedic and general surgical conditions, within the multi-trauma setting, with an emphasis on a multidisciplinary approach to the coordination of the complex physical, psychological and social issues that often surround these patients. At the conclusion of their attachment, interns should be competent in the recognition and management of common trauma-related disorders and the potential associated complications.

Staff Specialist in Emergency Department This position is responsible for the overall coordination, management and placement of trauma patients. Acts as resource for the ED Registrars and assists in trauma team activation as required.

Trauma Case ManagerThe Trauma Case Manager (TCM) coordinates the care and management of the multi-system trauma patients, providing leadership, expert clinical advice and support for patients, carers and other health care professionals. The TCM plays a significant liaison role allowing improved continuity of care during the patients’ transition through the many phases of hospital care.

Trauma Clinical Psychologists, Trauma Physiotherapists, Trauma Occupational Therapists, Trauma Speech Pathologist, Trauma Social workers, Trauma Dietician, Trauma PharmacistTogether with medical and nursing staff, dedicated Allied Health personnel adopt a team approach in the recovery process, rehabilitation phase and discharge planning of the trauma patient.


Trauma Program ManagerThe Trauma Program Manager provides administrative direction, leadership and support for the operational, educational, research, quality improvement and strategic management of the State Adult Major Trauma Service.

Injury Prevention Research NurseThis position focuses on community-led injury prevention and education programmes. A significant initiative to date has been the Prevent Alcohol Risk-Related Trauma in Youth (PARTY Program), which is delivered weekly to approximately 38 schools per year, in addition to Outreach programmes for those schools unable to attend. This program is also delivered to Juvenile Justice clients as part of the Court Diversionary process, and has been expanded to incorporate regional sites such as Bunbury, Denmark and Albany, with plans to further expand to other regional and rural centres such as Busselton.The RPH Trauma Service would also like to acknowledge the additional, and very valuable, input from the RPH Pastoral Care Team and the RPH Drug and Alcohol Support Service (DASS).


18. Education and research

Trauma grand rounds Meetings are held monthly, (February to December) and present an opportunity for departments within the hospital to present topics relevant to trauma. The presentations generally consist of a case review, combined with a review of current literature and trauma registry data. On occasion, these case reviews may be replaced by presentations by invited guest speakers on topics related to trauma.

List of Trauma Grand Round presentations for 2015

Month Topic PresenterFebruary Splenic preservation and associated

issuesDr Amyn Pardhan, Trauma Fellow, Matt Jacob, Trauma Intern

March Review of minor head injury Dr Ben Caruthers, ED Registrar

April Management options for penetrating abdominal wounds

Dr Amyn Pardhan, Trauma Fellow

May Occult Pneumothorax Dr Richard Leslie, ED Registrar

June No trauma Grand Round

July Peloton Pitfalls: Pedal cyclist trauma at RPH

Dr Thomas Cordery, ED Registrar

August Forensic Pathology and Trauma Dr Daniel Moss, MBBCh FRCPA MFFLM Forensic Pathologist, PathWest Laboratory Medicine

September Haemostatic Resuscitation: So what’s new?

Dr Angela Okereafor, ED Registrar

October No Trauma Grand Round

November Ocular Trauma Dr Tegan Phillips, ED RegistrarDecember 10 Year Retrospective Review of Trauma

mortality at RPHDr Sana Nasim, Trauma Fellow

Current collaborative research projectsSafer cycling in the urban road environment - Professor Lynn Meuleners, Director, Curtin Monash Accident Research Centre (C-MARC).The aim of the study is to propose modifications to the urban environment that will reduce injuries to cyclists. The study is aligned with two National Research Priorities namely: 1) an environmentally sustainable Australia and 2) promoting and maintaining good health.


The specific objectives of the research are:Objective 1: To describe the contributing factors to cyclist crashes in urban road environments

in Western Australia and Victoria.Objective 2: Identify features of the urban road environment that increases the risk of a cyclist

crash in Western Australia and Victoria. Objective 3: To develop road infrastructure prototypes that improves cyclists’ safety. Objective 4: To trial and evaluate the effectiveness of the prototypes in a bicycle simulator

(BikeSim).

In-depth analysis of pedestrian serious injury collisions - Professor Lynn Meuleners, Director, Curtin Monash Accident Research Centre (C-MARC).This study will provide a comprehensive understanding of the contr ibuting behavioural and environmental factors (road environment and vehicle) to pedestrian crash and injury risk. This information will be used to provide a detailed set of recommendations for implementation of innovative and cost-effective countermeasures to provide a safe walking environment. The findings of this study can be used to achieve significant reductions in pedestrian deaths and serious injuries in Western Australia.

Cost incurred by the Health System as a result of motorbike accidents in western Australia – Dr Maran Sinnathamby, Trauma Fellow, RPH. A five-year prospective study.

The cost of injury in Western Australia 2000 to 2014 – Delia Hendrie, A/Professor Rachael Moorin and Ted Miller, Centre for Population Health Research, Curtin University. This study examines the cost of all causes of injury in WA. Risk factors associated with high-cost injury cases will be identified for all cause injury cases, with additional analyses for road-related injury cases.

Detailed multivariate analysis of factors influencing road crash injuries using Linked Hospital, Main Roads, Death, Insurance, Trauma and Licensing Data – Max Maller, Ann-Marie Chapman, Ellen Ceklic, Data Linkage Branch, DoH; Dr Matthew Legg, Kirsty Kirkman, Office of Road Safety (Road Safety Commission).To evaluate the influence of the multiple risk factors associated with road crashes since 1995, and their consequences, in terms of specific injuries, severity, treatment required and the health services consumed.1) Explore the exposure, road, traffic and environmental factors associated with crash occurrence

and severity (primary safety).2a) Explore the vehicle, crash and personal dynamics within different crash scenarios (e.g. type of

crash – multi-vehicle/single-vehicle, type of vehicles and other road users - pedestrian, cyclist).2b) Explore the personal factors affecting injury severity such as age and gender, together with

seating position, on injury outcome (secondary safety).3) Explore the emergency response and treatment factors influencing survival given a certain set

of injuries has occurred (tertiary safety).4) Estimate the direct and indirect costs associated with crashes and injuries (burden of injury),

through incorporation of information derived from all hospital, emergency and third party insurance records that follow the index crash event.

Traumatic injuries of the aorta and surrounding vascular system in the chest and abdomen – Dr Kishore Sienaurine, Dr Stephanie Pederson, Dr Sudhakar Rao.Aims: to evaluate the prevalence and outcomes of management of patients with traumatic injuries to the aorta in the chest and abdomen, within RPH, and their eventual outcomes.


Calculating Injury Severity Scores from Hospital, Trauma and Death Records in WA – Max Maller, Ann-Marie Chapman and Ellen Ceklic, Data Linkage Branch, DoH.Aim: to develop, assess and extend the ICD0Based Injury Severity Score (ICISS), and other injury severity scores and store the results so that this added value can be made available for use in a range of approved road safety, community safety and injury related research projects.

Role of follow-up imaging studies in blunt splenic and liver injuries: A four year study from A Level 1 Trauma Centre – Dr Nikhil Agrawal and Dr Sudhakar Rao, RPH Trauma Service.The exact value of follow-up computed tomography in the non-operative management of blunt splenic and liver injuries is not yet defined. Although follow-up studies have been recommended to detect possible complications of the initial injury, we want find the evidence for follow-up CT scans and their effect on management of these patients.Objective: to determine whether follow-up imaging influences the management of patients with blunt splenic and liver injury.

Assessment of the current timing of spinal cord injury decompressive surgery – A Retrospective analysis of the last years of Austin Health spinal cord injury patients admissions – Professor Sue Dunlop and A/Proffesor John Buchanan et al, in conjunction with Austin Health, Victoria.To determine the average time to decompression in cases of SCI within Victoria over the last three years.To determine where substantial delays occur as patients move from the accident scene to surgery.To develop methods and protocols for overcoming these delays and streamlining the movement of patients from the accident scene to surgery.

Frailty in ICU trauma patients: A prospective observational study – Dr Megan Harold, Physiotherapy Department, RPH.Aim:1. To determine whether frailty predicts short and long term mortality in the trauma intensive care

population. 2. To determine whether frailty predicts short and long term functional outcome in the trauma

intensive care population. 3. To determine which of two frailty measure more effectively predicts mortality and functional

outcome. 4. If frailty is predictive of mortality and functional outcome, determine if it predicts more effectively

than other patient measures (i.e. age, co-morbidities, injury severity).

Frailty in the critically ill population is yet to be thoroughly investigated and is not yet investigated in the trauma population. The results of this study will add to the growing knowledge around the impact of frailty in the critically ill trauma population and provide insight into the most effective predictors of mortality and functional outcomes.Detailed assessment of risks and benefits of Inferior Vena Cava Filters on patients with complicated injuries (The Da Vinci Trial) - Professor Kwok Ming Ho, Dr Sudhakar Rao, Professor Rene Zellweger, Dr Stephen Honeybul, Clinical Professor Tomas Corcoran, Dr Philip Misur, RPH, Dr Cyrus Edibam, FSH, Professor Elizabeth Geelhoed, School of Population Health, University of Western Australia.


Venous thromboembolism (VTE) is a significant health problem especially in hospitalised patients, with a high-associated morbidity and mortality. For most patients, the standard of care is to use blood thinning drugs (prophylactic anticoagulation such as heparin). There is a group of patients who are at very high risk of VTE but these types of drugs cannot be used (e.g. severe brain injury). In these patients, the options are to use no/minimal intervention or to insert an Inferior Vena Cava filter (IVCF). Although IVCFs are widely used as a mechanical VTE prophylaxis in patients who have contraindications to conventional VTE prophylactic measures, their effectiveness in this situation has not been established. This phase III randomized controlled trial aims to assess the clinical effectiveness, benefits and harms, and also the cost-effectiveness of the early use of IVCFs (<72 hours of admission after severe injury) for trauma patients who have contraindications to pharmacological VTE prophylaxis. There is definitely equipoise to do such a study because, to date, the trauma community is split down the middle as to whether IVCFs are effective at all despite they are widely used for decades. National Health and Medical Research Council’s (NHMRC) 2009 clinical practice guidelines for the prevention of VTE do not give guidance on the appropriate use of IVCFs but state that there is a significant gap in the evidence for several VTE prophylactic agents including ‘the appropriateness of IVCFs in trauma patients.’ This trial has the capacity to influence the management of trauma patients worldwide, and to establish the place of IVCFs in modern medical practice.

PublicationsHo KM, Rao S, Burrell M, Weeramanthri T (2015) The Journey from Traffic Offender to Severe Road Trauma Victim: Destiny or Preventative Opportunity? PLOS ONE DOI:10.1371/journal.pone.0122652 April 22, 2015Mazahir S, Pardhan A, Rao S (2015) Office hours vs After-hours. Do Presentation Times Affect the Rate of Missed Injuries in Trauma Patients? Injury 49(4) · January 2015Pardhan A, Mazahir S, Rao S, Weber D (2015) Blunt Traumatic Abdominal Wall Hernias: A Surgeon’s Dilemma. World Journal of Surgery 40(1) · October 2015Baschera D, Hooman R, Collopy D, Zellweger R (2015) Incidence and clinical relevance of heterotopic ossification after internal fixation of acetabular fractures: retrospective cohort and case control study. J Orthop Surg Res, 10:60, DOI: 10.1186/s13018-015-0202-z.


19. Injury prevention

Prevent Alcohol Risk-related Trauma in Youth (P.A.R.T.Y)The Prevent Alcohol and Risk-related Trauma in Youth (P.A.R.T.Y.) program based at RPH is a dynamic, interactive health promotion program for youth. It is intended to promote injury prevention through reality education, enabling youth to recognise risks, make informed choices, and learn about potential traumatic consequences. This program allows youth to experience the journey of an imaginary trauma patient through the ED, ICU and Trauma unit at RPH. The knowledge gained of the journey from injury through to rehabilitation, especially where drugs/alcohol or risk taking behaviour was a contributing factor, could lead to a reduction in related trauma incidences, this could ultimately lead to a reduction in injury and mortality rate. According to a Perth study published in 2012, “attendance of the P.A.R.T.Y. youth injury awareness program was associated with a change in the attitudes of the juvenile justice offenders about risk-taking behaviour and significantly reduced their subsequent risk of injuries and committing traffic- or violence-related offences” (Ho, et al., 2012). The licensed program, which originated in 1986 in Sunnybrook, Canada, has been operational at RPH through Trauma Services since 2006. As of December 2014, over 8,300 Western Australian teens have participated in the Perth program. It continues to be overwhelmingly popular, and already has bookings for 2016. The program has expanded to include a satellite P.A.R.T.Y. program in Bunbury at South West Health Campus that commenced in 2011 with over 900 youth attending the Bunbury program. In 2014, Albany Health Campus was given the opportunity to commence a pilot P.A.R.T.Y. program, thanks to Office of Road Safety funds. It is anticipated that they will continue the program after the pilot program has finished. The pilot sites of Geraldton and Denmark are exploring funding to continue to provide local, regionally adapted programs for their communities. Opportunities to further expand and accommodate more youth from both metropolitan and regional areas are currently being explored, with a P.A.R.T.Y. Roadshow and Outreaches recently being conducted in Karratha. A modified P.A.R.T.Y. program has also been delivered in conjunction with members of the Department of Aboriginal Health, to engage with and empower Aboriginal youth.The P.A.R.T.Y. program day is facilitated by the P.A.R.T.Y. Program Coordinator, an experienced clinical nurse with a trauma-related background. Groups of 20 – 30 students attend weekly in school term, the target group is youth aged 14 – 19 years. The program incorporates a ‘behind the scenes’ hospital tour, with a series of presentations from passionate doctors and nurses in each area, ideally students meet and talk to consenting trauma patients on the wards. A Headwest expert teaches students about traumatic brain injury, and students hear first-hand about the lived experience from a brain injured person. Students also talk with Drug and Alcohol Support Service experts, and learn about pre-hospital care from a St John Ambulance Paramedic. Presentations from the Public Transport Authority of Western Australia have also been included in the program in 2014. A highlight for students is the hands-on physiotherapy session, where they gain an insight into life with a spinal cord injury and rehabilitation post trauma. The day concludes with an ambassador from the Paraplegic Benefit Fund sharing their personal story of spinal cord injury, here, students begin to realise the full impact of traumatic injury. Written consent is gained prior to attendance from parents and students, and pre, post and 3 – 5 month evaluation questionnaires are collected by the P.A.R.T.Y. team for research and quality control purposes.


20. Appendices

Appendix i Monthly quality improvement database queriesAbdo region not 4 or 6 Ambulance applicable but date or reference is nullAmbulance not applicable but date/time yes Blood products – time in ED is null Blunt cause of trauma C-spine region not 1 Cause of trauma is null Chest region not 3 or 6 Dialysis out date nullDirect Admit (Triage is not null)Dispatch from ED is nullEd Dispatch to ICU – LOS is null Ed Dispatch to SMTUA – LOS is null (minors)ED null valuesExternal region not 6 (abdo)External region not 6 (burns)External region not 6 (chest)External region not 6 (face)External region not 6 (lower limb)External region not 6 (neck)External region not 6 (scalp)External region not 6 (upper limb)Extremities region not 5Face region AIS not 2FCI is null Invalid region 1 AIS Invalid region 3 AIS

Invalid region 4 AISInvalid region 5 AISInvalid region 6 AISL-spine region not 4Marital status or race is nullMinors ISS > 15Mode of arrival is nullNeck AIS not region 1 or 6Null ISSNull values in trauma detailsOccupation code is nullPenetrating cause of traumaPost ED null valuesProvider null valuesProvider time difference > 24 hours Residential institution trauma discharge homeRPRH null valuesReady date and timeSafety device is null for MBA/MVAScoring null valuesSpecialist area date/time nullSpecialist EDSTUA date/time is nullTriage not null Direct AdmitT-spine region not 3Trauma date > 7 days before arrival dateVehicular cause details null


Appendix ii Health regions of Western Australia Source: http://www.health.wa.gov.au/services

Metropolitan Hospital Services

North Metropolitan Health Service Sir Charles Gairdner HospitalOsborne Park HospitalJoondalup Health CampusSwan Kalamunda Health ServiceKing Edward Memorial Hospital for WomenGraylands Hospital

South Metropolitan Health ServiceRoyal Perth HospitalArmadale Health ServiceBentley HospitalFiona Stanley HospitalFremantle Hospital Peel Health Campus Murray District HospitalRockingham General Hospital

Non-Metropolitan Hospital Services

South westAugusta HospitalBoyup Brook Soldiers Memorial HospitalBridgetown HospitalSouth West Health Campus (Bunbury Hospital)Busselton HospitalCollie Hospital Donnybrook Hospital Harvey HospitalWarren HospitalMargaret River HospitalNannup HospitalNorthcliffe Nursing PostPemberton HospitalYarloop Hospital

Metropolitan otherPrincess Margaret Hospital for ChildrenMetropolitan Private Hospitals

Goldfields Coolgardie Health CentreEsperance District HospitalKalgoorlie Health CampusKambalda Health CentreLaverton HospitalLeonora District HospitalMenzies Health CentreNorseman HospitalVarley Nursing Post

KimberleyKununurra HospitalWyndham HospitalBroome Health CampusDerby HospitalFitzroy Crossing HospitalHalls Creek Hospital


Non-Metropolitan hospital services cont’dwheatbeltBeverley Health ServiceBruce Rock Memorial Health ServiceBoddington Health ServiceCervantes Nursing PostCorrigin Health ServiceCunderdin Health ServiceDalwallinu Health ServiceDumbleyung Memorial Health Service Goomalling Health ServiceKellerberrin Memorial Health Service Kununoppin Health ServiceKondinin Districts Health ServiceKukerin Health CentreLake Grace Health ServiceMerredin Health ServiceMoora Health ServiceMukinbudin Health CentreNarembeen Memorial Health Service Narrogin Health ServiceNortham Health Service Pingelly Health CentreQuairading Health ServiceSouthern Cross Health ServiceWagin Health ServiceWickepin Health CentreWilliams Health CentreWongan Hills Health ServiceWyalkatchem-Koorda Health ServiceYork Health Service

Great SouthernAlbany HospitalBremer Bay Health CentreDenmark Hospital and Health ServiceGnowangerup HospitalJerramungup Health CentreKatanning HospitalKojonup HospitalPlantagenet HospitalTambellup Nursing Post

Pilbara Marble Bar Nursing PostNewman HospitalNickol Bay HospitalNullagine Community Health ServiceOnslow HospitalParaburdoo HospitalHedland Health ServiceRoebourne HospitalTom Price HospitalWickham Health Centre

Midwest Carnarvon Multipurpose ServiceCoral Bay Nursing PostCue Health CentreDongara Eneabba Mingenew Health ServiceExmouth Multipurpose ServiceGeraldton HospitalKalbarri Health CentreMeekatharra HospitalMorawa Perenjori Health ServiceMount Magnet Health CentreMullewa HospitalNorthampton HospitalNorth Midlands Health ServiceSandstone Health CentreYalgoo Health Service

Non-Metropolitan Private Hospital non-Metropolitan other

Interstate /Overseas


Appendix iii Injury Severity Score and Abbreviated Injury ScaleThe Injury Severity Score (ISS) is a method of describing patients with multiple injuries and for evaluating emergency care. Developed by Baker et al., (1974), ISS provided “a valid description of the overall severity of injury in persons who have sustained injury to more than one area of the body”.The ISS utilises Abbreviated Injury Scale (AIS) codes. These codes were developed by the American Association for Automotive Medicine and have been revised to produce the AIS-2005. The AIS assigns a 6-digit code to every injury. This code is based on the anatomical site, the nature, and severity of the injury. The last digit of the AIS code indicates the severity of the injury as listed below.

AIS Severity1. Minor2. Moderate3. Serious, not life threatening4. Severe, life threatening5. Critical, survival uncertain6. Maximum, fatal.NB: an additional code of 9 is utilised if the severity is unknown.

The ISS is best described as the sum of the squares of the highest AIS code in each of the three most severely injured ISS regions.

ISS Regions1. Head or neck (includes C-spine)2. Face (includes eyes, mouth, nose and facial bones3. Chest (includes Thoracic Spine, diaphragm)4. Abdominal or pelvic contents (includes Lumbar Spine)5. Extremities or pelvic girdle (includes sprains, #, etc.)6. External (includes lacerations, abrasions, burns etc.).


Appendix iv Trauma clinical indicators and auditsThe following Key Performance Indicators have been adopted from the 2012 consensus review by Santana et al3 of ‘evidence-informed quality indicators of adult injury care’. This review was conducted through a systematic literature review and international audit of 133 verified trauma centres in United States, Canada, Australia and New Zealand. Thirty one evidence-informed quality indicators of adult injury were developed, which were shown to have content validity and deemed useful perf ormance measures to guide injury care quality improvement practices.

1. Direct admission to ED Resuscitation Room

Relationship to quality Medical care should be timely

Type of indicator Hospital process, hospital level

Proposed data sources ED Triage Form, EDIS, ED Trauma Form

Definition Number of injured patients with physiological compromise* directly admitted to ED shock room (trauma/resuscitation) per 100 ED admissions (per cent)

Numerator All injured patients age eighteen years and older with physiological compromise* and admission to the ED shock room (trauma/resuscitation) in 10 minutes or less of ED arrival

Denominator All injured patients age eighteen years and older with physiological compromise* admitted to the ED

SQL Folder: query Key Performance Indicators: 1. Direct Admission to the ED Resuscitation Room

Benchmark Not specified at present

Australian Trauma Registry Not defined at present

Risk adjustment Not applicable

Registry modification †Admission to Resus on arrival to ED; ISS >15

Comments following review (2015)

Five patients Direct Admit to ICU, pre-intubated, following secondary hospital transfer

Results

* Proposed parameters of physiological compromise (RR < 10 or >29 breaths per minute or intubated or GCS < 9 or SBP < 90 mmHg) are derived from the field triage published by the CDC1,2. They are designed to provide simple identification of patients with physiological compromise that may benefit from direct admission to the ED resuscitation room, but can be replaced by local guidelines if available.

† The Trauma Registry only capture patients admitted directly to the Resuscitation Area, i.e. patients who may have commenced their admission in another area, prior to being transferred to Resus due to deterioration, will not be captured.

References1. Centres for Disease Control and Prevention (CDC). CDC – Injury Prevention and Control: Field Triage Guidelines for the Field Triage

of Injured Patients. 2011; http://www.cdc.gov/fieldtriage/index.html. Accessed July 8, 2012.2. Sasser SM, Hunt RC, Sullivent EE, et al. Guidelines for field triage of injured patients. Recommendations of the National Expert Panel

on Field Triage. MMWR Recomm Rep. 2009;58(RR-1);1-35.


2. Trauma Team Activation (TTA)

Relationship to quality Medical care should be safe

Type of indicator Hospital process, hospital Level

Proposed data sources Hospital Medical Record, ED Trauma Form

Definition Number of injured patients admitted to ED who satisfy local TTA guidelines and for whom there is a TTA per 100 patients* (per cent)

Numerator All injured patients aged eighteen years and older admitted to the ED who satisfy local TTA guidelines and for whom there is a TTA*

Denominator All injured patients aged eighteen years and older admitted to the ED who satisfy local TTA guidelines *

SQL Folder: query Key Performance Indicators: 2.Trauma Team Activation (TTA)


Australian Trauma Registry Not defined at present


Registry modification ISS >15

Comments following review (2015)

Data reliant on documentation in the medical record and therefore may be under-reported.

Results

* Local TTA guidelines employed (refer to Appendix vi)Rainer et al.1 suggested that compliance with Trauma Team Activation protocols optimised process of care and improved survival. Reference1. Rainer TH, Cheung NK, Yeung JH, Graham CA. Do trauma teams make a difference? A single centre registry study. Resuscitation.

2007;73(3):374-381.Rainer TH, Cheung NK, Yeung JH, Graham CA. Do trauma teams make a difference? A single centre registry study. Resuscitation. 2007;73(3):374-381.


3. Tracheal intubation

Relationship to quality Medical care should be safe


Proposed data sources Hospital Medical Record, ED Trauma Form, Trauma Registry

Definition All injured patients aged eighteen years and older with documented decreased level of consciousness (GCS < 9) in the ED and with successful insertion of endotracheal tube in the ED

Numerator All injured patients aged eighteen years and older with documented decreased levelof consciousness (GCS < 9) in the ED

Denominator All injured patients aged eighteen years and older with documented decreased level of consciousness (GCS < 9) in the ED

SQL folder: query Key Performance Indicators: 3.Tracheal Intubation


Australian Trauma Registry Collected – awaiting implementation of KPI

Risk adjustment Not specified at present

Registry modification Initial GCS only measured on arrival to ED†; ISS >15

Comments following review of outliers (2015)

Five patients reviewed and deemed appropriate palliation

Results

†Trauma Registry only records initial observations and does not capture patients who deteriorate during Emergency Department stay.The American College of Surgeons Committee on Trauma proposed the indicator Comatose Trauma Patient Leaving the ED before Mechanical Airway Established1

Reference1. American College of Surgeons Committee on Trauma. Resources for Optimal Care of the Injured Patient 2006. Chicago: American

College of Surgeons; 2006


4. Time to CT scan

Relationship to quality Medical care should be timely


Proposed data sources Hospital Medical Record; ED Trauma Form; Trauma Registry; PACS

Definition ED patients with blunt force injuries and trauma team activation criteria (TTA*) or ED documented GCS <9, time to CT within one hour of arrival per 100 patients

Numerator All ED patients (ISS >15) aged eighteen years and older with blunt force injuries and TTA* or ED documented GCS <9 and time to CT < one hour

Denominator All ED patients aged eighteen years and older with blunt force injuries and TTA* or ED documented GCS <9

SQL Folder: query Key Performance Indicators: 4. Time to CT (Procedure)


Australian Trauma Registry Collected


Registry modification ISS >15; Includes: only includes CT performed at the definitive hospital; *Local TTA guidelines employed

Comments The results of this KPI reflect processes in the Emergency Department regarding clinical decision making and development of a definitive management plan. Significant work needs to be done to streamline this process.

Results

* Local TTA guidelines employed (refer to Appendix vi)Body region for CT scan is not specified. Panellists highlighted this as a very important system indicator that is designed to encourage early CT and CT guided therapy. They also indicated that it may be a surrogate measure of whether the trauma team is working well. They emphasised the importance of time for certain injuries (e.g. brain injury), but noted that it is unclear what time threshold is most appropriate other than the general criteria that earlier is better.The indicator is an amalgamation of two indicators, Time to Body CT and Time to Head CT, previously proposed by Chadbunchachai et al.1,2.References1. Chadbunchachai W, Saranrittichai, S, Sriwiwat S, Chumsri J, Kulleab S, Jaikwang P. Study on performance emonitoring following Key

Performance Indicators for trauma care: Khon Kaen Hospital 2000. J Med Assoc Thai. 2003;86(1):1-72. Chadbunchachai W, Sriwiwat S, Kulleab S, Saranrittichai, S, , Chumsri J, , Jaikwang P. The comparative study for quality of trauma

treatment before and after the revision of trauma audit filter, Khon Kaen Hospital 1998. J Med Assoc Thai. 2001;84(6):782-790


Mortality auditA multidisciplinary panel of trauma specialists reviews all trauma deaths. Each death is determined to be preventable, possibly preventable or not preventable, according to in-hospital patient management and potential system errors. Where appropriate, recommendations for improved patient care are made to Service 4 and the Director of Clinical Services.Of the 110 trauma deaths eligible for audit in 2015, 85 patients (77.3 per cent) have been reviewed to date. A trauma registry Key Performance Indicator (KPI) recommends that all trauma deaths be reviewed within 90 days of data complete (80 per cent target threshold). However it is the trauma registry’s policy that, where applicable, deaths will only be eligible for review after sighting of the autopsy report to confirm injuries. In 2015, 88.23 per cent of eligible trauma deaths to date were reviewed within the 90 day KPI recommendation. This shows an increase in compliance on 2014 (85.96 per cent). The biggest challenge faced by the trauma registry in meeting the KPI is the availability of the patient’s medical records. Other compounding factors include delay in obtaining autopsy reports, resulting in delay to data complete and the number of patients that can be reviewed at audit. Smarter work practices are also impacting this figure by allowing the Trauma Registry Research Nurses to complete the review of more deceased patients than the Mortality Audit Committee are able to review in a 12 month period. Currently there are 11 patients that are data complete awaiting review at audit. The number of records being audited at alternate Mortality Audit Committee Meetings was increased from eight records to ten records in 2012 in an attempt to catch up on backlog. In 2013 the Trauma Service Resident Medical Officers (RMOs) began reviewing six deceased patients per month, as part of their ongoing education and professional development. These patients are presented by the Trauma Service RMOs to a panel of nursing and medical staff and if required, the reviewed patients can be referred to the Main Mortality Audit for further discussion. This has allowed 11 additional audits to be conducted in a 12 month period.A total of 23 mortality audits were conducted in 2015, reviewing 161 patients.

The cause of death determined at audit is as follows:

Cause of death Number of patientsAcute myocardial infarction 8Brain death 19Cardiac arrhythmia 5Cardiac failure 5CVA 3Haemorrhage 15Head injury 53Multi organ failure 20Other 3PE 1Respiratory failure 13Respiratory infection 13Sepsis 2Unknown 1Total 161


The following trauma management issues were discussed:• Adequate securing of IV cannula prior to transfer.• Consider jugular vein access in presence of lower limb injuries.• Early clarification – Improved documentation of NFR order where appropriate, to avoid MET Calls.• Use of nasopharyngeal airway in suspected base of skull fractures.• Difficulties of use with IO gun in pre-hospital setting.• Continuation of neurological observations in ED beyond initial set. • Identification and flagging of ‘special populations’ at triage – in particular elderly patients

with minor head injuries who are on anticoagulants.• Futility of surgery in patients with non-survivable head injury.• VTE Prophylaxis.• ED thoracotomy in blunt trauma – appropriateness.• Palliation and care of dying patient. • Traumatic cardiac arrest versus medical cardiac arrest.• Prioritisation of procedures in ED.• Management of dysphagia.• Need for documentation of advice provided by the Trauma Service to referring practitioners.• Initiation of femoral nerve block catheter in ED.• Options for consideration of IVC filter.• Opioids and pain management.• Prioritisation of patients for theatre. • Escalation of medical response for MET criteria.• Cessation and recommencement of Clopidogrel for Orthopaedic cases (#NOF).

Trauma management issues highlighted through this audit are dealt with in a number of ways:• education and feedback to relevant clinician(s)• development of policies/protocols/guidelines• review and monitoring for trends.

Missed injuries auditA panel of Emergency Medicine and Trauma specialists conduct weekly audits of injuries that were missed until after the secondary survey of trauma patients at RPH (since ED). In addition, cases with injuries that are initially missed in the first ED presentation and who subsequently require admission for management (delayed diagnosis), are reviewed. In each case, the reviewers attempt to determine the reason for the injury being missed initially, e.g. inadequate examination, inadequate history, inadequate or no investigation, wrong interpretation of investigation results and limitation of investigation. The audit panel also reviews the clinical significance of the missed injury to the patient, such as caused death, disability permanent, disability transient, required additional surgery, no clinical impact and other (e.g. increased length of stay). An additional data point specifying whether the missed injury was identified before, during or after the tertiary survey has been added during 2014. Audit results are fed back to individual ED and Trauma Services doctors where appropriate. Senior staff use the audit forum to identify ways of improving patient assessment that will potentially reduce the number of missed injuries in the future. Junior staff attending the audit are exposed to the types of injuries commonly missed and how to avoid making the same mistakes.


In 2015, 136 patients had 350 missed injuries (2.5 per cent of patients). Eleven of these patients had delayed diagnosis after initial assessment and discharge. 239 injuries from 2015 have been audited. Of the injuries missed, the median ISS was 17, with a range of 2 – 59. There were 34 injuries that were considered to be appropriately missed on further review. Of the remainder, the region with the most missed injuries was the upper extremities (74), followed by lower extremities (58), then spinal injuries (44). The most common cause for missing injuries was inadequate examination (108) followed by limitation of investigation (32). There were no deaths or permanent disability due to missed injuries. Most had transient disability (119), with the remainder having required additional surgery (42), no clinical impact (44), increased length of stay (5) or no comment made at audit (29). Most patients had their missed injury diagnosed before (89) or at (14) the tertiary survey. Of the remainder, 71 injuries were diagnosed after tertiary survey, 29 did not require a tertiary survey (i.e. admitted under a non-surgical specialty) and responses were not recorded in 37 cases. This data has provided the trauma service with a benchmark to improve upon in the coming years.

Emergency Department Trauma Form auditThe Emergency Department Trauma Form is a resource which may guide junior medical officers in the initial assessment of the trauma patient. An audit is conducted at the beginning and end of each rotation of trauma residents, to assess the level of compliance with regard to the completion of this form. The aim of the audit is to improve the standard of documentation on the ED form, and provide feedback to the medical team regarding areas which may need attention. Ultimately this should improve patient care, by providing clear documentation of the patient’s journey from the scene to the conclusion of their Secondary Survey.The audit is conducted at the start of each residents trauma rotation (Part A), and again at the end of their rotation (Part B). The results of Part A are fed back to the team, with a view to improving documentation standards for the remainder of the term. Once Part B is completed, the two results of the audit are compared to each other and presented in a report for feedback to the team once again. The ED Form audit has now been running for almost three years. Some areas of the ED Form are generally always good, such as compliance with the patient sticker being on the form, and documentation around the method of injury and the Secondary Survey. There has been a gradual improvement regarding the documentation of pre-hospital care, such as fluids and observations. It is vital this information is readily available to clinicians so that they are able to make safe decisions about fluid and medication prescription, with knowledge of what the patient has already received prior to their arrival at RPH. There are some areas of the form which still need some work, such as compliance with senior doctors’ signing off the Secondary Survey and management plan prior to the patient being transferred from ED to the ward areas. However, the ED Form audit is an ongoing process, and it is hoped that there will be continued improvements.

Trauma Tertiary Survey Audit Patients who present to hospital after sustaining traumatic injuries should be evaluated in a systematic and thorough manner, to ensure that all injuries are identified, and thus treated appropriately. Using Advanced Trauma Life Support (ATLS) principles, patients should be evaluated in ED using the primary and secondary surveys. However, in some cases, these surveys may not detect all the injuries that the patient has sustained. For example, the patient may be intoxicated due to drugs or alcohol and thus unco-operative at the time of presentation, or they may have life threatening injuries that require prioritisation and immediate life saving measures.The Trauma Tertiary Survey has been developed in order to ensure that all injuries that the patient has sustained are identified and treated in a timely manner. A Trauma Tertiary Survey is a formal, repeated examination of the patient undertaken after initial resuscitation and treatment have taken place, and assist in identifying injuries not found on initial presentation.


At RPH, all patients admitted meeting the Trauma Team Activation Criteria must have a Trauma Tertiary Survey completed before being transferred to another ward or before being discharged, as per the Trauma Service Operational Guidelines. The Trauma Tertiary Survey Form, which is a four page document, should be conducted within 48 hours of admission.The Trauma Tertiary Survey Form Audit aligns with the following strategic planning objectives:a. To provide high quality, timely and efficient services.b. To promote a coordinated approach in the provision of area and state-wide healthcare services.c. To be recognised as a ‘centre of excellence’ for research and evidence-based practice.d. To fulfil the education and training role of a leading teaching hospital objective.

The Trauma Tertiary Survey Form is used not only by the Trauma Team to assess the patient and produce a comprehensive management plan, but also other members of the team, such as ward nurses and the wider multidisciplinary team. The Trauma Registry Research Nurses use this form as a source of information from which data is collected.The Trauma Tertiary Survey Form Audit commenced in June 2014, and initially was conducted on a monthly basis with feedback provided to the Trauma team. Since then the audit process has been refined and the audit is now bi-termly, taking place two weeks after the commencement of the RMO rotation (Part A), and two weeks prior to the completion of the rotation (Part B) for comparison, utilising an electronic audit tool on Survey Monkey. This provides a more meaningful evaluation of any improvements in the documentation on the Trauma Tertiary Survey Form. It is hoped that the audit will continue to develop and the feedback it generates will be used to improve the standard and accuracy of documentation on the Trauma Tertiary Survey Form. The aim is to produce a report at the end of each term and a cumulative report at the end of each year.

Critical incident auditQuality improvement programmes are necessary to monitor and, if required, improve the standards of care for hospitalised patients. A critical incident is defined as “an incident that resulted, or could have resulted in an adverse outcome for the patient” (Zingg et al, p 1420). Complications that occur in patients have the potential to increase costs, both physical and financial, to the individual and institution.The aim of the Critical Incident Audit is to identify and review critical incidents involving patients that are admitted to the RPH State Major Trauma Unit. A key emphasis is on critical thinking and reflective practice – could this incident have been pre-empted or managed differently? Since 2013 there has been an emphasis on the importance of referral to the formal Clinical Incident Management System (CIMS) process where appropriate. A graph is included to show the number of CIMS referrals that have been initiated (Figure 2).Examples of criteria for Critical Incidents can be seen in Table 1.


Table 1: Criteria for Critical Incidents

Internal criteria External criteria• Trauma Team Activation (TTA) criteria met –

team not called/delayed• Helicopter should have been considered for

primary/secondary retrieval• Medical Emergency Team activation (MET) • Did not bypass secondary metropolitan

hospital• Unplanned return to theatre • Significant delays at referring hospital

(country or metro)• Transfer to ICU/HDA from SMTU • Direct referral to another admitting team (i.e.

not Trauma) where Trauma team activation criteria applies

• Intubation/respiratory support (CPAP, BiPAP) etc. required

• Other

• Cardiac Arrest• DVT/PE• Death• Other

The incident is then audited by a panel consisting of:• Trauma Director.• Trauma Consultant.• Trauma Fellow/Registrar.• Trauma Programme Manager.• SMTU Nurse Unit Manager.• SMTU Staff Development Nurse.• Trauma Case Manager.

Results:In 2015 a total of 56 patients who had critical incidents were identified and reviewed.

Figure 1: Categories of critical incidents that occurred.


Table 2: Issues discussed at Critical Incident Audits

IssuesParavertebral Regional AnaesthesiaFluid ResuscitationDevelopment of State Major Trauma Unit guidelines for transport of critically unwell patientsCritically unwell patients Iv Access (2 X Large Bore Cannulas In Situ)Difficult Surgical Airway PlanProcess to ensure all investigations are reviewed Discharge planning and involvement of the multi-disciplinary teamUse of Cementless Prosthesis during Femur ORIFBlunt Abdominal Trauma AlgorithmOptimisation of patients having surgery Trauma team involvement in patients having surgeryBlunt Chest Trauma ProtocolSJA Bypass processVTE Prophylaxis guidelines

Figure 2: CIMS referrals

ReferenceZingg, U., Zala-Mezoe, E., Kuenzle, B., Licht, A., Metzger, G., & Platz, A. Evaluation of critical incidents in surgery. British Journal of Surgery, 2008; 95: 1420-1425


Appendix v data usage 2015

Topic Purpose Request From DateAll aortic and branch injuries (whole database to 2013)

Audit on outcomes of management of traumatic injuries to the aorta

Mr Kishore Sieunarine Consultant Vascular Surgeon, RPH

06/01/2015

Seatbelt usage 2003 – 2013

Extension of Traumatic Abdominal Wall Hernia study

Dr Adam Philpoff, Trauma Registrar, RPH

08/01/2015

Cycling Trauma to 2014

Media request – The West Australian

Hayley Noblett 08/01/2015

Cyclists data 2004 – 2013

Study Patrick Thornton, Resident, RPH 09/01/2015

MBAs 2014 Update to MBA study DR Maran Sinnathamby, Trauma Fellow, RPH

13/01/2015

Variables update to 2014 for all Trauma Registries

Data Linkage Branch projects Tom Eitelhuber A/Manager Data Linkage Branch Department of Health, WA

16/01/2015

Cyclists data 2010 – 2014

Feasibility for potential study Robin Roeters Medical Student, Trauma Service RPH

23/01/2015

Monthly admissions Meeting with hospital executive Mr S. Rao, Director of Trauma, RPH 20/02/15Patients “struck by object” as cause of trauma

PARTY statistics Ms M. Copeland, RPH PARTY Co-ordinator

23/02/15

Spinal patients Operational matters Mr S. Rao, Director of Trauma, RPH 23/02/2015Massive Transfusion patients

Update for ongoing study Dr Dustin HallHaematology Registrar, RPH

24/02/2015

Cervical Spine injuries 2013 –2014

Update for ICED study Sherilyn Nolan SCIPA Site Co-ordinator, Royal Perth Hospital

17/03/2015

Spinal injuries Briefing note Damian JollyBusiness ManagerService 4 RPH

17/03/2015

Cost of injury data Update for Data Linkage Project

Delia Hendry 13/03/2015

Tranexamic acid use in the ED

Clinical audit David McCutcheon, ED /Trauma Service Consultant

13/3/2015

Pneumothorax presentations

Trauma Grand Round on Occult Pneumothorax

Richard Leslie, ED Registrar 01/05/2015

Spinal #’s in over 65yo (count)

Presentation to physiotherapists

Fiona Coll, Senior Physiotherapist 01/05/2015

IVC Filter patients Presentation for ATS 2015 Elizabeth Shelton, RMO, RPH 07/05/2015Renal Trauma Presentation at RACS 2015

Annual Scientific CongressMr S. Rao, Director of Trauma, RPH 01/05/2015

IVC Filter patients Clinical Audit project Dr Elizabeth Shelton, RMO, RPH 07/05/2015Lung and ribcage injuries

Presentation at Trauma symposium

Fiona Coll, Senior Physiotherapist 08/05/2015

Road trauma stats Channel 7 media request Niki Theodoropoulos, Manager Public Relations, RPH

11/05/2015


Kangaroo–related trauma 2004 – 2014

Research project Dr Suren Subramaniam, Registrar, RPH

19/05/2015

Major Trauma admissions January – March 2015

Trauma Triage Audit Dr Adam Philpoff, Trauma Registrar, RPH

22/05/2015

Helicopter retrievals 2003 – 2015 (to date)

Presentation at WA State Trauma Symposium

Clinton van der Westhuyzen, Critical Care Paramedic, SJA

28/05/2015

Road Trauma stats RPH 2010 - 2015

Operational Matters Mr S. Rao, Director of Trauma, RPH 04/06/2015

Drug and Alcohol-related Trauma 2013

Policy Development – Nursing Practice Standard

Sally Simpson, Staff Development Educator, The Education Centre Royal Perth Hospital

08/06/2015

Pedal cyclists: comparing year 2007 to year 2014

Trauma Grand Round Presentation

Dr Thomas Cordery, ED Registrar, RPH

19/06/2015

Helicopter transfers 2005 – 2014

Operational matters Mr S. Rao, State Director of Trauma

02/07/2015

Assaults 2014 Media enquiry Niki Theodoropoulos, Manager Public Relations, RPH

14/07/2015

Statewide trauma registry data 1995 - 2014

Data Linkage – cost of Injury Project (data update)

Data Linkage Branch, DoH 21/07/2015


Data Linkage – calculating ISS Project (data update)

Data Linkage Branch, DoH 18/08/2015


Data Linkage/Road Safety Commission – internal data validity check

Ellen Ceklic, Data Linkage Branch, DoH

21/09/2015

Major Trauma 2005 - 2014

Trauma Grand Round Sana Nasim, Trauma Fellow, RPH 08/10/2015

Hypothermia 2011 - 2014

Post Grad Studies Hannah LubranoED Nurse, RPH

22/10/2015

Cyclist trauma 2014 Media request Caitlin Swarts, Public Relations, RPH

27/10/2015

Alcohol and drug related trauma

Presentation to Executive, education sessions

Ms T. Sinclair, Drug and Alcohol CNC

27/10/2015

Trauma in the older person

Presentation at Trauma Management course

Dr T. Gooneratne, Geriatric Medicine Registrar

28/10/2015

Unstable Pelvic factures 2010 - 2014

Presentation ASC 2016 Dr Roshan Nair, Registrar, RPH 05/11/2015

ISS for SMTU patients Nutritional Audit Dr Kirsten Biddle, Inter, SMTU, RPH 23/12/2015


Appendix vi RPH Trauma Team Activation Guidelines

Appendix vii Abbreviated Injury Scale (AIS) and Organ Injury Scale (OIS) codes for solid organ injury

The new

W h e r e t r a d i t i o n p l u s i n n o v a t i o n e q u a l s e x c e l l e n c e© State of Western Australia, Department of Health 2015 healthywa.wa.gov.au RPH M150429007

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Royal Perth Hospital Two Tiered Trauma Call Criteria

Special PopulationsElderly have a higher mortality for a given injury severity. Physiologic derangements can be masked by co-morbidities and medications. Early trauma team involvement should be considered. Vital signs should be interpreted in light of the patients usual cardiovascular parameters.There should be a low threshold for trauma team activation in paediatric patients. Any deviation from age appropriate vital signs should trigger a Hospital Trauma Response.

Age Resp. rate (breaths per minute)

Heart rate (beats per minute)

Systolic blood pressure (mm Hg)

<1 year 30 – 40 110 - 160 70 – 902-5 years 25 – 30 95 - 140 80 – 100

5-12 years 20 – 25 80 - 120 90 – 110>12 years 15 – 20 60 - 100 100 – 120

Obstetric +/- neonatal consultation should be obtained for pregnant trauma patients (see Obstetric trauma protocol on Servio)Trauma Group Page (The message is sent out to the following)Sudhakar Rao Gen Surg Registrar ED CNS Transfusion Medicine ICU Senior RegistrarTrauma Fellow Duty Anaesthetist ED RadiographerTrauma Registrar Orthopaedic Consult RMO ED PCATrauma RMO Orthopaedic Research AssistantTrauma InternTrauma Programme ManagerTrauma Case ManagerTrauma Unit CNS

Activate Hospital Trauma Response (Trauma B) when any of:Physiologic criteriaRR<10 or >29 SBP<90 at any time since injuryHR<50 or >120GCS<9AnatomicAirway compromiseMechanismPenetrating injury to head, neck, torso (including proximal to elbows or knees)Other considerations Multiple patients

Activate ED Trauma Response(Trauma A) when any of:Physiologic criteriaGCS<14Anatomic criteriaFlail chestMultiple body regions injured2 or more proximal long bone fracturesAmputation/crush injury proximal to wrist or ankleDegloved or mangled extremitySuspected spinal injuryBurns>15%Open or depressed skull #Pelvic fracturesMechanismMVA>60 kphMBA >30 kphPedestrian or cyclist versus carEjectionFatalityFall>3mCabin intrusion (>30cm occupants side, or >45cm any side)

Trauma Team ActivationText pagingIdeally messenger paging should be used to alert the Trauma Group page with a concise description of the expected patient(s). This can be used to request the presence of the Duty Anaesthetist in ED for an anticipated difficult airway for example or provide physiological parameters.(See below for the personnel included in the Trauma Group page).

Pre-programmed telephone pagingThe “green phone” (No:48797) in main flight deck and phone in CC15 next to X-ray viewing monitor (No:41777) can be used to send standardized messages.

Dial 3, wait for prompt, key in function (A or B), wait until “message sent”, hang up.

The page is delivered to the Trauma Group. The message sent is:

Trauma A: ED Trauma Team Activated

Trauma B: Hospital Trauma Response. Surgical Leader to attend. Anaesthetist to call 41777.

AVPU


Appendix vii Abbreviated Injury Scale (AIS) and Organ Injury Scale (OIS) codes for solid organ injury

Splenic injury544299.2 Spleen NFS 544210.2 contusion, haematoma 544212.2 subcapsular, <50 per cent surface area,intraparenchymal, <5cm in diameter,

minor,superficial [OIS I, II] 544214.3 subcapsular, >50 per cent surface area or expanding, ruptured subcapsular or

parenchymal, intraparenchymal >5cm in diameter or expanding, major [OIS III]544220.2 laceration NFS shattered = NFS until proven otherwise 544222.2 simple capsular tear <3cm parenchymal depth and no trabecular vessel involvement, minor, superficial [OIS I, II] 544224.3 no hilar or segmental parenchymal disruption or destruction, >3cm parenchymal depth or involving trabecular vessels,moderate [OIS III] 544226.4 involving segmental or hilar vessels producing major devascularization of >25 per cent of spleen but no hilar injury, major [OIS IV] 544228.5 hilar disruption producing total devascularization, tissue loss, avulsion, massive [OIS V]544240.3 rupture NFS

Renal injuries541699.2 Kidney NFS 541610.2 contusion, haematoma NFS 541612.2 subcapsular, nonexpanding, confined to renal retroperitoneum, minor,superficial [OIS I, II] 541614.3 subcapsular, >50 per cent surface area or expanding, major, large [OIS III]541620.2 laceration NFS 541622.2 <1cm parenchymal depth of renal cortex, no urinary extravasation, minor,superficial [OIS II] 541624.3 >1cm parenchymal depth of renal cortex, no collecting system rupture or urinary extravasation, moderate [OIS III] 541626.4 extending through renal cortex, medulla and collecting system, main renal vessel injury with contained haemorrhage, major [OIS IV] 541628.5 hilum avulsion,total destruction of organ and its vascular system [OIS V]541640.4 rupture NFS

Hepatic injuries541899.2 Liver NFS 541810.2 contusion,haematoma NFS 541812.2 subcapsular, <50 per cent surface area, or nonexpanding, intraparenchymal <10cm in diameter, minor; superficial [OIS I, II] 541814.3 subcapsular, >50 per cent surface area or expanding,ruptured subcapsular or Parenchymal,intraparenchymal >10cm or expanding, major [OIS III]541820.2 laceration NFS 541822.2 simple capsular tears,<3cm parenchymal depth,<10cm long, blood loss <20 per cent by volume, minor, superficial [OIS II] 541824.3 >3cm parenchymal depth, major duct involvement, blood loss >20 per cent by volume, moderate [OIS III] 541826.4 parenchymal disruption of >75 per cent of hepatic lobe, multiple lacerations >3cm

deep, “burst” injury, major [OIS IV] 541828.5 parenchymal disruption of >75 per cent of hepatic lobe or >3 Couinard’s segments within a single lobe,or involving retrohepatic vena cava/ central veins, massive complex [OIS V] 541830.6 hepatic avulsion (total separation of all vascular attachments) [OIS VI]541840.4 Rupture NFS

Reference:Association for the Advancement of Automotive Medicine. Abbreviated Injury Scale 2005 © Update 2008.


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