Trauma Registry

1
Trauma Registry

• The top ten missing data elements/information,
  that we nag facilities about

2

• Remember that patient care comes before
  documentation!!!!!!

3
Why is documentation so important?

• If its not documented than it wasnt done!
• Documenting for legal reasons
• Documenting for reimbursement dollars
• But most importantly you document the patients
  story!!!!!
• How can we evaluate care if we dont document
  !!!!

4
Carols top ten nagging abstract items!

• 10. EMS has incomplete or NO GCS and Vital Signs
• 9. NO EMS Trip Report in the Medical Record
• 8. EMS does not document the time that
  interventions took place for the patient
• 7. Place of injury is missing
• 6. SSN, Race, Gender, and Payor information
  incomplete

5
Carols top ten nagging Abstract items

• 5. Incomplete ED VS including temperature and
  route
• 4. Incomplete ED GCS
• 3. No Oxygen application by EMS and ED staff
• 2. Use of the cardiac monitor for all trauma
  patients
• 1. Using the Trauma Flow Sheet for all
  moderately to severely injured patients

6
10. EMS GCS and Vital Signs

• Why is this important?
• Glasgow Coma Scale or GCS, is a neurological
  scale which aims to give a reliable, objective
  way of recording the conscious state of a person,
  for initial as well as subsequent assessment.

7
EMS Vital Signs

• Another important patient care intervention that
  provides information to the provider
• Also provides information to the receiving
  facility in order that they can plan, organize
  and prioritize care of the trauma patient

8
9. NO EMS Trip Report in the Medical Record

• Why would we care to know what happened in the
  field?
• Tells the story of the patient while in the
  pre-hospital field
• All Trip Reports including Interfacility
  Transfers and any care provided by EMS at the
  scene should be documented even if EMS did not
  transport!!

9
NO EMS Trip Report in the Medical Record

• Provides information to the receiving facility in
  order that they can plan, organize and prioritize
  care of the trauma patient
• How can we evaluate care if there is no
  documentation

10
Reasons for missing EMS Trip Reports

• Not done by EMS
• Need to get back to community to provide 911
• Left in the ED with patient, but it is thrown
  away
• No place to leave the trip report in the ED
• Medical Records staff dont think it needs to be
  in the medical record because EMS care did not
  take place at this facility

11
EMS not documenting times for interventions

• C-spine Immobilization
• VS, including SA02
• Oxygen application
• Cardiac monitor
• IV
• Splinting/wound care

12
Why should EMS provide times?

• It tells the story of the patient while in the
  pre-hospital setting.
• Care can be evaluated in the pre-hospital setting
  for performance improvement.

13
Place of Injury

• Try to be as specific as you can about the
  place of injury.
• Street/Highway - I-15, I-90, MM215 if possible
• But always document the nearest town, city to
  the accident

14
6. SSN, Gender, Race and Payors

• SSN used as a patient identifier in the Central
  registry (just makes identifying the patient
  easier)
• Gender really have to know if male or female
• Race the State as well as nationally is
  tracking who is getting injured and looking for
  trends and areas to target injury prevention
• Payor insurance reimbursement
• Also trended nationally

15
Incomplete VS in the ED

• Need an accurate baseline for the patient
• Compare initial VS in the ED to those taken in
  the Field (stable vs unstable)
• Take the temperature on EVERY PT!!!!

16
Why Temperature is so important in the Trauma
Patient

• Adverse Effects of Hypothermia
• Cardiac dysfunction
• Coagulation dysfunction
  Altered mental
  status
• Confusing physiology
• Decreased survival

17
Lethal Triad in Trauma

• Hypothermia, along with acidosis and coagulopathy
  are the lethal triad in injured patients.

18
4. Incomplete ED GCS

• Each element of GCS is used to come up with the
  aggregate score.
• The more it is used the easier it becomes to use
  when you need to, for a patient that is altered
• How do we evaluate a patients responsiveness if
  no neurological tool is used
• AVPU okay - but not as accurate in documenting
  what may be altered
• EVERY PATIENT in the ED should have a GCS
  documented!!!

19
G
GCS Score (E M V) Best Possible Score
15 Worst Possible Score 3
20
3. 0xygen application

• Oxygen needs to be applied to all
• trauma patients no matter their
• oxygen saturation!!
• Apply Oxygen initially by NRB
• ATLS guidelines state
• 02 is to be administered to all trauma
• patients no matter their oxygen saturation

21
2. Cardiac monitor

• Apply the cardiac monitor initially to ALL trauma
  patients
• Discontinue it later after
• identification of injures, illness
• and the stability
• of the patient has been identified
• or it has been determined that this
• intervention is no longer needed in the care of
  the patient

22
1. Trauma Flow Sheet

• Use for all trauma patients
• It helps provide cues about documentation and
  care
• Dont make them complicated
• Use the paper abstract as a tool to develop a
  flow sheet
• Place them where staff have easy access and will
  use them all the time!

23

• Remember That Patient Care Comes Before
  Documentation!!!!

24

• QUESTIONS?