Trauma Systems in Canada: Evolution, Challenges, and Strategies for Improving Trauma Care for Rural Patients

This thesis explores the development and current state of trauma systems in Canada, emphasizing the challenges and disparities faced by patients who are injured in rural areas. With trauma being the leading cause of death for Canadians under 40, effective trauma systems are crucial. However, patients injured in rural and remote areas face significant barriers to timely and adequate trauma care, resulting in increased morbidity and mortality. This body of work aims to evaluate some of these disparities and propose strategies for improvement.\nThe concept of organized trauma systems has its roots in ancient wartime practices, evolving significantly over centuries. Despite significant progress, rural trauma care in Canada remains challenging. Approximately 20% of the Canadian population resides more than one hour away from a Level I or II trauma center. This geographical disparity significantly impacts the timely delivery of trauma care.\nTo begin to address some of these challenges, this thesis consists of four interconnected projects aimed at addressing rural trauma care disparities:\nHistorical Review of the Development of Trauma Systems: This comprehensive literature review traces the evolution of trauma systems from their earliest conception to their modern iterations. The goal is to demonstrate how the continuous evolution of trauma systems influences the delivery of trauma care today. It highlights the need for continuous improvement to enhance current systems and ensure care for those who are underrepresented within existing frameworks.\nReinforcing the Role of Rural Trauma Laparotomy: This retrospective matched cohort study compares outcomes of patients undergoing damage control laparotomy (DCL) at rural hospitals (RH) prior to transfer to lead trauma hospitals (LTH) with those directly admitted to LTHs. The hypothesis is that timely DCL at RHs is associated with comparable outcomes to DCL completed at LTHs. Twenty-one patients who underwent RH-DCL before being transferred to a LTH were compared to 21 matched patients who received DCL directly at the LTH. Analysis demonstrated no statistically significant difference in abdominal-specific complications including surgical site infection, anastomotic leak, and fistula formation. Secondary outcomes including ICU length of stay, overall hospital length of stay, and mortality rates were also similar between the two groups. These findings suggest that with proper training and support, RHs can effectively perform DCL, potentially improving outcomes by reducing delays in hemorrhage and contamination control.\nEvaluating the Impact of Advanced Trauma-Team Leader Notification: This pre- post- intervention cohort study assesses a recent policy change in Ontario requiring advanced notification of trauma team leaders (TTL) for incoming hemodynamically unstable patients. By comparing patient outcomes before and after the policy implementation, the study aims to identify the benefits of early TTL involvement, and to serve as a pilot for a larger provincial study. Results indicated a trend towards significance in reduction in time to critical interventions, such as surgery or chest tube placement, following the policy change. The completion of this study solidified methodology to allow for inclusion of the remining four level 1 equivalent trauma centres in the province to address the provincial impact of this new policy.\nSurvey of Ontario Surgeons and Trauma Directors: These two related but distinct surveys address perspectives of community general surgeons and trauma medical directors (TMDs) with respect to their understanding of the above-mentioned policy change, and to identify perceived barriers to delivering trauma care in rural settings.The survey revealed a varying level of awareness and comfort regarding the new protocols. Community surgeons captured in the study appear to be comfortable in performing emergency surgery for trauma patients, however, barriers such as blood product availability and timely transport were identified. Additionally, TMDs highlighted the challenges in maintaining consistent communication and coordination with RHs and felt that there was a lack of comfort preventing community surgeons from performing emergent surgery for trauma patients. The survey underscored the need for standardized training programs, improved resource allocation, and robust communication systems to ensure rural healthcare providers are well-equipped to handle severe trauma cases.\nThis thesis underscores some of the unique challenges in improving trauma care for rural populations in Canada. Despite advancements in trauma systems and the establishment of designated trauma centers, geographic and resource-based disparities continue to hinder the delivery of timely and effective care to rural trauma patients. The results of the work contained in this thesis provide data to support opportunities for improvement in care provided at a population level to minimize the impact of severe injury.

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