Trauma Registry: The Nuts & Bolts of Data Collection Karla Bryan, RN, BSN Trauma Coordinator EIRMC

Trauma Resuscitation Overview Report received from EMS; trauma page goes out Report received from EMS; trauma page goes out Pt. arrives in ED 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 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) Assessment, stabilization, procedures, tests (plain films/CT, angio, FAST)

What precludes thorough data collection? The Trauma Bay Environment The Trauma Bay Environment Recorder: Primary RN or dedicated recorder Recorder: Primary RN or dedicated recorder The number of trauma team members in the room The number of trauma team members in the room Intense team activity: assessment, stabilization, diagnostics Intense team activity: assessment, stabilization, diagnostics Charting after the fact Charting after the fact

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

Getting the Necessary Information Know what you need Know what you need ITR, ACS, NTDB ITR, ACS, NTDB Look in depth at ED chart for needed data elements Look in depth at ED chart for needed data elements Take information to your director Take information to your director Meet with ED Director/Manager: be prepared to show ITR requirements, what is lacking on chart (if cues aren’t there, info won’t be collected) Meet with ED Director/Manager: be prepared to show ITR requirements, what is lacking on chart (if cues aren’t there, info won’t be collected) Work with core group of ED RNs to revise chart to get required data elements Work with core group of ED RNs to revise chart to get required data elements

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

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

 Per review of nursing documentation only. TS Timeliness L1/L2 1 st -2 nd Q 2006 (n =93)

 Per review of nursing documentation only.  3 cases > 15 mins. TS Timeliness L1/L2 1 st -2 nd Q 2006 (n = 90)

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

Appropriateness of Activations ALL 1 st -2 nd Q 2006 (n=465) ACS EXPECTED RATE Under triage 5-10%Over triage 30-50%

Appropriateness of Activations L1 1 st -2 nd Q 2006 (n=23)

Appropriateness of Activations L2 1 st -2 nd Q 2006 (n=75)

Appropriateness of Activations L3 1 st -2 nd Q 2006 (n=367)

Data abstraction/entry Don’t guess-if the information isn’t documented, mark as unknown Don’t guess-if the information isn’t 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 Check your abstraction form for missing data elements and do your data entry before you return the chart to medical records Remember—garbage in, garbage out. Check your data against other reports Remember—garbage in, garbage out. Check your data against other reports Continue to update nurses on what’s missing from documentation Continue to update nurses on what’s missing from documentation Use your data: Report to ED, QI Dept, Physicians, Administration, Others Use your data: Report to ED, QI Dept, Physicians, Administration, Others