Trauma Registry: The Nuts

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Trauma Registry The Nuts Bolts of Data
Collection

• Karla Bryan, RN, BSN
• Trauma Coordinator
• EIRMC

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Trauma Resuscitation Overview

• Report received from EMS trauma page goes out
• Pt. arrives in ED
• Met by resuscitation team at least 2 MDs, 2 RNs,
  Lab, X-ray, Respiratory Therapist, Pharmacist,
  Scribe, House Supervisor, Social Services,
  Security, CT Tech, EMS
• Assessment, stabilization, procedures, tests
  (plain films/CT, angio, FAST)

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What precludes thorough data collection?

• The Trauma Bay Environment
• Recorder Primary RN or dedicated
  recorder
• The number of trauma team members in the
  room
• Intense team activity assessment,
  stabilization, diagnostics
• Charting after the fact

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Recording Extremes

• Difficult Pt. arrives from MVC, ejected,
  comatose, obvious open femur fx, open tib/fib fx,
  distended abdomen, respiratory distress
• Easy Pt. arrives after being bucked off horse,
  c/o sore back, obvious forearm fx, no neuro
  deficits, VSS, alert/oriented.

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Getting the Necessary Information

• Know what you need
• ITR, ACS, NTDB
• Look in depth at ED chart for needed data
  elements
• Take information to your director
• Meet with ED Director/Manager be prepared to
  show ITR requirements, what is lacking on chart
  (if cues arent there, info wont be collected)
• Work with core group of ED RNs to revise chart to
  get required data elements

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• ED staff meetings
• Describe the purpose of the registry
• Describe the needed data elements
• Ask staff for ideas of how best to collect needed
  data elements (buy-in)
• Describe how data can/will be used can benefit
  them for presentations they do in the
  community/hospital

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• ED staff meetings continued
• Describe necessity of accurate data collection
  for PI purposes
• Examples
• Physician timeliness ACS
  requirement
• . (Our solution- team members
• names on glass trauma doors)

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TS Timeliness L1/L2 1st-2nd Q 2006
(n 93)

• Per review of nursing documentation only.

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TS Timeliness L1/L2 1st-2nd Q 2006
(n 90)

• Per review of nursing documentation only.
• 3 cases gt 15 mins.

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• PI examples for ED staff meeting cont.
• Triss Need ISS, RTS (systolic BP, RR,
  GCS), Age, Blunt/Penetrating
• Appropriateness of Activation without
  documentation of mechanism, injuries,
  unable to determine

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Appropriateness of Activations ALL 1st-2nd Q
2006
(n465)
ACS EXPECTED RATE Under triage 5-10 Over triage
30-50
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Appropriateness of Activations L1 1st-2nd Q 2006
(n23)
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Appropriateness of Activations L2 1st-2nd Q 2006
(n75)
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Appropriateness of Activations L3 1st-2nd Q 2006
(n367)
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Data abstraction/entry

• Dont guess-if the information isnt documented,
  mark as unknown
• Check your abstraction form for missing data
  elements and do your data entry before you return
  the chart to medical records
• Remembergarbage in, garbage out. Check your data
  against other reports
• Continue to update nurses on whats missing from
  documentation
• Use your data Report to ED, QI Dept, Physicians,
  Administration, Others

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