Abstract

BackgroundThe documentation of physician arrival is an important component of trauma resuscitation. The American College of Surgeons (ACS) requires attending physicians at Level I and Level II trauma centers to arrive to the most critical traumas, full trauma team activations (full activations), within 15 minutes at 80% compliance, and to limited trauma team activations (limited activations) within a timely manner, which we designated as 60 minutes. However, our institution’s rates of documentation and compliance using a paper-based trauma flowsheet (TFS) were found to be well below the 80% compliance rate.MethodsPhysicians began using a radio-frequency identification (RFID) badge to swipe into the emergency department (ED) upon arrival to the trauma room. Arrival times were taken from the swipes data and used to supplement missing or non-compliant times on the TFS. If a TFS was missing a time, it was considered both undocumented and noncompliant. A two-proportion z-test was used to compare the rates of documentation and compliance before and after the addition of swipes data.ResultsDocumentation rates for full activations rose from 76% to 90%. Compliance rates for full activations rose from 70% (below the requirement) to 84% (compliant). Limited activation documentation and compliance rose significantly from 47.2% and 45.3% to 67.4% and 63.4%, respectively. Total documentation rose significantly from 49.9% to 69.7%. We went from below compliance to above compliance with the addition of the RFID system.ConclusionThe use of the RFID technology improved the rates of documentation and compliance of attending physician arrival to trauma activations. Rates rose between 14 and 20 percentage points in each category, significantly in total documentation and in limited activation documentation and compliance. The addition of RFID swipes data made our rates improve to become compliant.

Highlights

  • IntroductionDue to the large volume of data that needs to be recorded, a single nurse is typically designated to the role of scribing the events of the patient resuscitation during a trauma activation

  • Documentation is an important component of trauma care in the emergency department (ED)

  • Compliance rates for full activations rose from 70% to 84%

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Summary

Introduction

Due to the large volume of data that needs to be recorded, a single nurse is typically designated to the role of scribing the events of the patient resuscitation during a trauma activation. The paper-based trauma flowsheet (TFS) is a multi-page documentation tool previously used by a majority of trauma centers, the adoption of the electronic medical record (EMR) in recent years has reduced the number of paper-based TFSs in favor of electronic documentation. It contains designated areas for demographics, mechanism of injury, physician response time, and other vital measurements Our institution’s rates of documentation and compliance using a paperbased trauma flowsheet (TFS) were found to be well below the 80% compliance rate

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