Trauma Documentation Research Articles

MobileCARE- Innovative Approaches for Combat Trauma Education and Documentation

Learning Objectives: Mobile technologies harbor the potential to transform healthcare by improving clinician workflow and decision-making, which ultimately enhances quality of care and patient outcomes. The time sensitive nature inherent in trauma and critical care requires physicians to quickly access information to make correct decisions. In the past 5 years, we have been developing a mobile software platform and data management system that combines clinical documentation, education and telemedicine/decision-support. The goal is to provide clinicians with an integrated system of tools to facilitate the process of care. MobileCARE delivers a suite of integrated applications that completely supports a physician's workflow. Clinicians are able to create documentation, view test results, medical notes and surgical documentation in real time. It also provides access to a mobile learning trauma and critical care curriculum and the ability to communicate through telemedicine with other team members. To better understand the use of mobile technologies in the clinical environment, we conduct usability and user acceptance testing as a guide to implementation. We also have conducted knowledge and skill acquisitions tests of the learning modules.The system are currently being evaluated in the trauma intensive care unit of a busy urban Level 1 trauma center. Physicians use it to document patient admissions and daily patient status with the information immediately available to all users across multiple platforms. Knowledge and skill acquisition tests have demonstrated that the mobile learning modules are equivalent to traditional classroom lectures (Figure 1), and that their use improved performance in the simulated environment (Figure 2). MobileCare is a complete software solution that provides significant functionality in the clinical environment. The impact on the safe and efficient delivery of care will continue to be realized. This technology is especially beneficial where continuity of care is required, as with patients with chronic disease or multiple acute conditions.

Electronic Documentation of Trauma Resuscitations at a Level 1 Pediatric Trauma Center

Although many hospitals across the country have implemented an electronic medical record (EMR) for inpatient care, very few have successfully implemented an EMR for trauma resuscitations. Although there is evidence that the EMR improves patient safety, increases access to all care providers, increases workflow efficiency, and minimizes time spent on documenting thereby improving nursing care, the fast paced, complex nature of trauma resuscitations makes it difficult to implement such a system for trauma documentation. With the support of multiple disciplines with a variety of clinical knowledge, this article describes the design process that has led us to successful development and implementation of an EMR for documentation of trauma resuscitations.

Challenges developing evidence-based algorithms for the trauma reception and resuscitation project

A project based at the Alfred Emergency and Trauma Centre in Melbourne, Australia aimed to standardise trauma resuscitation, documentation and interventions by developing best practice algorithms. The primary study objective was to demonstrate a reduction in management errors using a real-time computer based algorithm (the study group) compared to the control group in an open randomised controlled interventional study. A baseline control group was also used for comparison with usual (current) practice. In order to examine the existing evidence and algorithms in trauma care, nine teams of emergency nurses and doctors were formed. Specific literature searches performed by each team revealed a paucity of evidence supporting clinical practice in the trauma setting for procedures. Subsequently, the multidisciplinary teams worked together and developed algorithms based on best practice. The process revealed three main areas of challenges in the development of algorithms: (i) clinical, (ii) research and (iii) nursing challenges. The completion of the project demonstrated benefits in the real-time computer based algorithm with a reduction in the error rate per patient from the baseline control group to the intervention study group (2.30 vs. 2.13, p=0.04) and error-free resuscitations increasing from 16% to 21.8% (p=.049). This project supported the implementation of a real-time computer based algorithm system with improved protocol compliance and reduced errors and morbidity.

Impact of standardized trauma documentation to the hospital's bottom line

The dichotomy between clinical and hospital revenue generation for trauma care is well established. Many trauma programs require hospital support for fiscal survival. We evaluated the impact of standardized clinical documentation to the hospital's bottom line at our trauma center. Standardized documentation templates for evaluation and management were created with a focus on accuracy and efficiency. Documentation was completed jointly by residents and faculty following standard guidelines of linkage. Trauma service characteristics, case mix index, reimbursement rate, payer distribution, hospital charges, cost, and payments were compared before and after standardization. Professional revenue was not evaluated. Analysis was performed using a commercially available spreadsheet computer application. A 24% increase in the hospital's net income for trauma care, constituting $1.45 million, was realized despite a 12% decrease in patient volume. Admission profitability increased by 42%. Collection rates and payer mix were unchanged. Increases in both injury severity score and case mix index were seen (P < .05) after implementation of the program. Length of stay was decreased significantly. An effective standardized documentation strategy for trauma care results in significant fiscal gains in hospital reimbursement.

Trauma- und Unfalldokumentation in Deutschland

The role of trauma documentation has grown continuously since the 1970s. Prevention and management of injuries were adapted according to the results of many analyses. Since 1993 there have been two different trauma databases in Germany: the German trauma registry (TR) and the database of the Accident Research Unit (UFO). Modern computer applications improved the data processing. Our study analysed the pros and cons of each system and compared them with those of our European neighbours.We compared the TR and the UFO databases with respect to aims and goals, advantages and disadvantages, and current status. Results were reported as means +/- standard errors of the mean. The level of significance was set at P<0.05.There were differences between the two databases concerning number and types of items, aims and goals, and demographics. The TR documents care for severely injured patients and the clinical course of different types of accidents. The UFO describes traffic accidents, accident conditions, and interrelations. The German and British systems are similar, and the French system shows interesting differences.The German trauma documentation systems focus on different points. Therefore both can be used for substantiated analyses of different hypotheses. Certain intersections of both databases may help to answer very special questions in the future.

Development of a Hospital-Based Trauma Registry in Haiti: An Approach for Improving Injury Surveillance in Developing and Resource-Poor Settings

Trauma-related morbidity and mortality are a growing burden in the developing world. However, usable injury data in resource-poor and developing settings is lacking. Trauma registries can improve injury surveillance to enhance trauma care, outcomes, and prevention. This article provides, by example from Haiti, an approach to developing a hospital-based trauma registry in a resource-poor setting. An assessment of trauma documentation was performed retrospectively with subsequent development and pilot testing of two injury surveillance systems. The system most promising for meeting the needs and capabilities of the institution was implemented. Retrospective medical record review from 1999 (n = 43) and 2002 (n = 43) revealed limitations in available data for trauma surveillance. Specific mechanism of injury was documented in 39.3% and 57.1% of 1999 and 2002 groups, respectively. Injury date and arrival vital signs were infrequently recorded. Two injury surveillance models were designed and pilot tested: provider-based (PTR) (pilot n = 19) and coordinator-based (CTR) (pilot n = 37) trauma registries. Analysis of the pilot testing resulted in revisions to operations and the trauma registry forms. Both registry models showed improved data collection compared with the retrospective study with CTR and PTR documenting specific mechanism of injury in 94.6% and 100% of patients, respectively. The PTR model was chosen for implementation at the hospital. Trauma registries in developing settings are plausible tools for injury surveillance. Successful trauma registries will be resource- and setting-specific in design and can potentially be the means by which trauma care and outcomes are improved, prevention programs are developed, and capacity-building goals realized.

Comparative Update on Documentation of Trauma in Seven National Registries

Introduction: The role of trauma documentation systems for trauma research has continuously increased since the first trauma registries were developed in the late 1980s. Data acquisition and processing improved highly, partly because modern computer and network technologies offer new approaches. International comparison is important for the learning process and the investigation of differences in the mechanisms of injury, rescue systems and treatment protocols. We demonstrate keypoints of the learning curve thus supporting a further spreading of trauma registries. Methods: Seven exemplary trauma registries from the United States, Canada, Victoria (Australia), United Kingdom, France, Germany and the new European Trauma Audit and Research Network registry were analyzed according to their development until the current status. Special investigations were conducted for data acquisition, inclusion criteria and the volume and characteristics of patient data. Results: We found a clear overall beneficial influence of the documentation systems on the respective trauma system. Data acquisition displayed a wide range of difference from paper forms being entered into a centralized database by hand to direct entry of the data into the database by a local user via an Internet platform. Some systems copy computerized patient data from local hospital systems. Two registries are available in two languages. One has the option to add further languages as demanded. Datasets are comparable in terms of general data and a compulsory trauma diagnosis. Still, the details of the documented period of care and the inclusion criteria differ considerably. Discussion: We describe the important role of several trauma registries within a trauma care system. Although the success is hard to measure, related publications, continuous growth, the official use for quality control and the demand to participate by other countries stress their wide spread acceptance (secondary internationalization). These advantages make trauma registries a valuable tool in many countries.

A Study on Trauma Documentation in Accident and Emergency Attendance Records

Aim To study the adequacy of trauma documentation in accident and emergency (A&amp;E) attendance records. Method We reviewed the A&amp;E attendance records of major trauma requiring trauma-team care in the resuscitation room from January to June 1999 and July to December 2001. Thirty-eight items including the history, symptoms and signs of injury were scored with reference to the teaching of the Advanced Trauma Life Support course. The mean score and rate of documentation of each item were calculated. Additional items on biomechanics and environmental factors of injury were also examined. The performance of emergency medicine trainees and non-emergency medicine trainees was analysed. Results A total of 128 records were included, 46 and 82 records being from 1999 and 2001 respectively. The maximum documentation score was 38. The mean documentation score in 2001 was 23.27; and this was significantly better than 20.37 in 1999 (p &lt; 0.05). The documentation rates of pre-hospital, biomechanics and environmental items were poor. Notably, 15 out of the 38 items were preformatted in the A&amp;E records and 11 of these preformatted items had documentation rates of &gt; 80%. Emergency medicine trainees had better scores in 2001 than in 1999. However, non-emergency medicine trainees did not show improvement in their documentation. Conclusion Trauma documentation has improved since 1999 for emergency medicine trainees. Preformatted charts may increase the rate of documentation. Information on pre-hospital care and injury mechanism was not well documented.

Use of the personal digital assistant for point-of-care trauma documentation

J Emerg Nurs 2001;27:516-8.

Experience with road traffic accident victims at The Nairobi Hospital.

To evaluate the clinical and epidemiological data on automobile injuries and to assess the adequacy of road trauma documentation at the Nairobi Hospital. A retrospective descriptive study. The Accident and Emergency Centre of the Nairobi Hospital. Medical records of randomly selected road trauma patients who presented at The Accident Centre between 1st July 1997 and 31st August 1998 were analysed. The mean age was 32 years with a peak incidence in the 21-30 year age group. Males comprised 63.1% of the injured. The predominant category of the road user injured was the vehicle occupant (70%). Pedestrians only constituted 21.3%. Major city roads or highways were the commonest scenes of injury (38.3%). Most of the responsible vehicles were small personal cars (65.8%). The public service minibuses (popularly known as matatu) caused 20% of the injuries. Most of the injuries were mild and transport of the injured to hospital was uniformly haphazard. A quarter of the injuries were severe enough to warrant admission. Trauma documentation was poor with less than 30% accuracy in most parameters. The pre-hospital and initial care of the injured is not systematized. The study calls for re-orientation of trauma care departments to the care of the injured.

Trauma and the elderly: A case study

Effective trauma management is a team effort. Communication and consultation between the team members is essential for smooth, efficient and sound trauma management. The challenges posed when caring for the elderly trauma patient will tax even the most proficient team. 60% of trauma deaths are patients aged over 55 years. The elderly undergo significant physiologic changes that disguise the normal stress response, such as arteriosclerotic arteries, reduced response to catecholamines, decreased cardiac output and myocardial contractility, muscular atrophy, decreased bone mass and decreased lung compliance. Other influencing factors are preexisting illnesses, current medications and the mechanism of injury. This case study illustrates the process of multi trauma in the elderly, the pathophysiology of pulmonary injury, pelvic fractures and hypovolemic shock as well as various management issues. Attention is drawn to the importance of communication between trauma team members and documentation as well as the significance of early consultation with the patient and family by senior medical staff regarding management and definitive care plans. The trauma nurse generally coordinates the patient care and the author highlights the importance of using all resources to obtain the highest level of care and efficient trauma management.

An audit of trauma documentation

Research into aspects of the care of the injured depends on accurate and complete documentation. Inadequate records make audit almost impossible and are unacceptable medico-legally. An audit was made of the standard of trauma documentation in the Yorkshire region before the introduction of trauma charts in 1992. After it was established that a problem did exist, an audit was made of the standard of documentation before and after introduction of trauma charts in one city teaching hospital. Case notes were inspected for completeness of documentation of respiratory, circulatory and neurological status. Results from 1988–1989 showed that only 39.4 per cent of notes recorded the four parameters under investigation. In 1992–1994 the standard had improved. Without trauma charts documentation increased to 90 per cent, but with trauma charts in primary referrals the result improved to 97 per cent. Only 56 per cent of notes were complete for tertiary referrals when a trauma chart was not used. The standard of documentation in major injuries improved with the use of trauma charts. It is recommended that trauma charts are used routinely for all primary and tertiary referrals of injured patients. Tertiary referral patients should be reassessed fully after hospital transfer and a new trauma chart completed.

Impact of a Statewide Trauma System on Rural Emergency Department Patient Assessment Documentation

To determine the association of rural ED patient assessment documentation with state trauma system implementation, hospital trauma categorization level (i.e., Level-3 vs Level-4), injury diagnosis, and patient demographics. A pre- vs post-system implementation (historical control) analysis of trauma documentation was performed using a sample of rural ED trauma patients from 4 Level-3 and 5 Level-4 trauma hospitals. The medical records of patients with specific index diagnoses in 4 anatomic regions (head, chest, liver/spleen, and femur/open-tibia) were reviewed for 3-year periods before statewide trauma system implementation and after hospital categorization. Vital sign, % inspired O2, and O2 saturation determinations were identified relative to the first and the last vital signs documented on the ED record. If not documented in the medical chart within 5 minutes of the first or last ED vital sign assessment, these measurements were considered missing. Separately, neurologic documentation (initial and final) also was sought for patients meeting criteria for an index head injury. Of 1,057 patients entered into the database, 532 were evaluated during the pre-system period and 525 were evaluated during the post-system period. Overall, 47% had a head injury, 34% had a chest injury, 23% had a femur/open-tibia injury, and 12% had a spleen/liver injury. There were 142 (13%) patients with an injury in > 1 index area. Except for initial systolic blood pressure, documentation of all other initial and final patient vital signs increased significantly (p < 0.05). Documentation of the Glasgow Coma Scale score (initial and final; p = 0.0001) and a final pupil examination on head-injured patients (p = 0.025) also increased. The effects of hospital level, injury diagnosis, and patient demographics on documentation rate were minimal. The study found overall improved ED documentation of trauma patient status in association with implementation of a statewide trauma system. This improvement in documentation suggests an enhanced process of care with trauma system participation.

Can memories of childhood sexual abuse be repressed?

We sought studies which have attempted to test whether memories of childhood sexual abuse can be repressed. Despite our broad search criteria, which excluded only unsystematic anecdotal reports, we found only four applicable studies. We then examined these studies to assess whether the investigators: (1) presented confirmatory evidence that abuse had actually occurred; and (2) demonstrated that their subjects had actually developed amnesia for the abuse. None of the four studies provided both clear confirmation of trauma and adequate documentation of amnesia in their subjects. Thus, present clinical evidence is insufficient to permit the conclusion that individuals can repress memories of childhood sexual abuse. This finding is surprising, since many writers have implied that hundreds of thousands, or even millions of persons harbour such repressed memories. In view of the widespread recent public and scientific interest in the areas of trauma and memory, it is important to investigate further whether memories of sexual abuse can be repressed.