Electronic Thesis and Dissertation Repository

Thesis Format

Integrated Article

Degree

Master of Science

Program

Surgery

Supervisor

Vogt, Kelly

2nd Supervisor

Gray, Daryl

Co-Supervisor

3rd Supervisor

Moffat, Brad

Co-Supervisor

Abstract

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.

The 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.

To begin to address some of these challenges, this thesis consists of four interconnected projects aimed at addressing rural trauma care disparities:

Historical 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.

Reinforcing 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.

Evaluating 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.

Survey 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.

This 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.

Summary for Lay Audience

Trauma is the leading cause of death for Canadians under the age of 40. While many people live close to hospitals that specialize in treating severe injuries, those living in rural and remote areas often face significant challenges in getting the urgent care they need. This research aims to understand these challenges and find ways to improve trauma care for rural Canadians.

The first part of the research looked at whether rural hospitals can effectively perform emergency surgery to control severe abdominal bleeding before transferring patients to larger trauma centers. We found that with proper training and support, rural hospitals have successfully performed these surgeries with outcomes similar to those patients who initially present to a trauma-designated hospital in an urban area.

We then examined the impact of notifying trauma teams at urban lead-trauma hospitals in advance about incoming patients with severe injuries. The research showed that early notification may allow trauma teams to prepare better and act faster when the patient arrives, leading to decreased times to potentially lifesaving intervention such as surgery.

The third part involved surveying surgeons in rural areas and trauma leaders in Ontario to understand the perceived challenges impacting rural hospitals. We showed that trauma leaders in Ontario perceive rural surgeon comfort to be a significant barrier in these patients receiving necessary surgery in rural hospitals. Further, while community surgeons felt that comfort was not an issue, barriers such as availability of blood products, surgical assistants, and timely transport may decreased their willingness to performing these operations.

This research, comprised of mainly pilot work, highlights the urgent need to improve trauma care for rural Canadians, who often do not receive the same level of care as those in urban areas. By empowering rural hospitals with the necessary skills and resources, ensuring better communication and coordination with larger trauma centers, and continually updating trauma care practices, we can provide better care to all Canadians, regardless of where they live.

Creative Commons License

Creative Commons Attribution 4.0 License
This work is licensed under a Creative Commons Attribution 4.0 License.

Download

Share

COinS