The impact of a qualified medical documentation assistant on trauma room management

Benjamin Lucas,Felix Walcher,Wiebke Schirrmeister,Gerald Pliske,Sophie-Cecil Mathieu,Martin Kulla

doi:10.1007/s00068-020-01513-y

Abstract

PurposeTo improve quality of trauma room management, intra- and inter-hospital benchmarking are important tools. However, primary data quality is crucial for benchmarking reliability. In this study, we analyzed the effect of a medical documentation assistant on documentation completeness in trauma room management in comparison to documentation by physicians involved in direct patient treatment.MethodsWe included all patients treated in the trauma room from 2016/01/01 to 2016/12/31 that were documented with the trauma module of the German Emergency Department Medical Record V2015.1. We divided the data into documentation by medical documentation assistant (DA, 07:00 to 17:00), physician in daytime (PD, 07:00 to 17:00), and physician at night (PN, 17:00 to 07:00). Data were analyzed for completeness (primary outcome parameter) as well as diagnostic intervals.ResultsThere was a significant increase in complete recorded data for DA (74.5%; IQR 14.5%) compared to PD (26.9%; IQR 18.7%; p < 0.001) and PN (30.8%; IQR 18.9; p < 0.001). The time to whole-body computed tomography (WBCT) significantly decreased for DA (19 min; IQR 8.3) compared to PD (24 min; IQR 12.8; p = 0.007) or PN (24.5 min; IQR 10.0; p = 0.001).ConclusionIn presence of a qualified medical documentation assistant, data completeness and time to WBCT improved significantly. Therefore, utilizing a professional DA in the trauma room appears beneficial for data quality and time management.

Highlights

For severely injured patients, effective diagnostics and treatment in the trauma room are crucial to the course of treatment and outcome of the patient
Unrecorded data occurred in the presence of the documentation assistant (DA) in 24.0% of cases (IQR 14.5%), while the values were 65.4% for PD (IQR 22.2%; p < 0.001) and 63.0% for PN (IQR 19.0%; p < 0.001 by Kruskal–Wallis test; Fig. 2)
This study investigated the significance of a qualified medical documentation assistant in the trauma room setting of a German level-one trauma center

Summary

Introduction

Effective diagnostics and treatment in the trauma room are crucial to the course of treatment and outcome of the patient. The survival rate of severely injured patients has improved from 63 to 78% [1, 2]. One important factor for improving treatment effectiveness and quality is the use of intra- and inter-hospital benchmarking [1]. The inter-hospital quality assessment of the German Trauma Society (TraumaRegister DGU®; TR-DGU) started with six German hospitals in 1993. More than 600 hospitals from 11 countries are participating [3, 4]. For German hospitals, participating in this registry is one of the requirements for the hospital’s certification as a trauma center (TraumaZentrum DGU®)

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