The Electronic Trauma Flow Sheet: What Does(n’t) Work – Part 1

There are two major problem areas using an electronic trauma flow sheet (eTFS): the front end and the back end. Today, I’ll discuss the front end data entry problems.

Trauma activations are very data intensive events. Beginning prior to patient arrival, there are registration activities so the electronic health record (EHR) can begin accepting other information about the patient. Once they arrive, there is a continuous stream of information regarding observations, actions, results, medications, fluid, blood, and much more. All of these occur during a relatively brief period of time. Some are simultaneous.

This stream of information continues after the patient leaves the trauma bay for CT, imaging, interventional radiology, operating room, ICU, or ward bed. The flow sheet scribe is charged with recording all of this information as contemporaneously as possible. This ensures accuracy of the data, particularly with events that occurred at the same time.

But there is a major difference in input between the paper trauma flow sheet and the eTFS. The paper sheet is typically a three or four page form that is laid out in front of the scribe. All of the data blocks are readily visible, and are grouped in logical clusters: prehospital information here, primary survey data there, procedures in that one, vitals and narrative there.

Unfortunately, it’s not so simple with the eTFS. The scribe can view whatever content fits on a single screen. And it is just not possible to display all of the needed info on that one screen. The software developers addressed this problem by creating multiple screens that can be accessed by clicking on various tabs or buttons. The problem is that the human cannot see where the blocks are and must be very familiar with the tabs and buttons. And to make it worse, they must shift between mouse click and keyboard to move between them and record data.

This results in a stream of input that can’t be recorded quickly enough to stay current. It is very common to see a “cheat sheet” next to the input terminal so the scribe can add quick handwritten notes when they get behind. This information is entered later, but as you may imagine, accuracy suffers. It is very common to see events or results that do not fit the timeline. Once this occurs, the entire record is suspect and will not represent the true flow of the resuscitation. And what about events that occur during patient transport, between computer workstations?

The difficulty of entering trauma resuscitation information in true real time results in a Garbage In situation. Tomorrow, I’ll continue with problems on the back end that can result in Garbage Out.


The Electronic Trauma Flow Sheet: Why Hospitals Want You To Switch

Today, I’ll kick off my series on use of the electronic trauma flow sheet (eTFS) with a list of the typical reasons used to justify it. 

Typically, hospital administrators pressure trauma programs to adopt an eTFS at some point after implementation of an electronic health record (EHR). For the most part, they give two reasons:

  1. We need to go paperless! The assumption is that all of the rest of the charting will be electronic, so the trauma flow sheet should be moved to this format as well.
    The reality is that there will always be some good, old-fashioned paper parts to the patient’s chart. Every hospital ward has a little cubby with some old-timey three ring binders for putting the scraps of paper that accumulate. These may be records from an outside referring hospital, a pre-hospital run sheet, blood bank tags from units of blood products, and other stuff. What typically happens to it? It gets scanned into the chart at some point. 
    So there is no reason that a paper trauma flow sheet can’t be scanned as well. The key move is that it should be scanned early so that it is available in the EHR as soon as it is complete.
  2. We need to see patient flow, vitals, meds, etc from the time they hit the door. We don’t want to miss the activity that occurs in the trauma bay, right?
    The care typically received in the trauma bay is what I would consider a singularity. It is like nothing else in the hospital stay in terms of pace, intensity, and level of activity. Being able to trend medication or blood administration from arrival through discharge is not that important. Vital signs during resuscitation may be nothing like those of the rest of the hospital stay. It’s just not that helpful to be able to connect that phase of care with the rest of it.
    But having said that, it may be helpful to be able to see all of the medications given during a hospital stay. Ideally, someone should go back and reconcile the medications after the fact. A pharmacist, perhaps?

Neither of these excuses really hold any water, so don’t get talked into trying out an eTFS because of them.

Tomorrow, I’ll write about why the eTFS doesn’t work during the trauma resuscitation phase of care.

Next Week: The Electronic Trauma Flow Sheet

It’s been a while since I visited the topic of the electronic trauma flow sheet (eTFS) for trauma activations. A few years have passed, the software engineers have gotten smarter (hopefully), so let’s look at it again.

Next week, I’ll be covering the eTFS in detail again. Here is what I will touch on:

  • eTFS: Why Hospitals Want To Switch
  • What Does(n’t) Work
  • Oops! Now What Are My Options?

I’d also like to spend a day on Q&A. To that end, please start emailing, commenting, or tweeting your questions so I can answer them in detail at the end of the week. Let the games begin!

Nursing Tips for Managing Pediatric Orthopedic Trauma

Nurses have a complementary role with physicians in caring for children with orthopedic injuries. Typically, the child will have been evaluated and had some sort of fracture management implemented. In children, nursing management is easer than in adults since a child is less likely to need an invasive surgical procedure. Many fractures can be dealt with using casts and splints alone.

Here are a few tips for providing the best care for your pediatric patients:

  • Ensure adequate splinting / casting. You will have an opportunity to see the child at their usual level of activity. If it appears likely that their activity may defeat the purpose of the cast or splint, inform the surgeon or extender so they can apply a better one.
  • Focus on pain control. Nothing aggravates parents more than seeing their child in pain! Make sure acetominophen or ibuprofen is available prn if pain is very mild, or scheduled if more significant. Ensure that mild narcotics are available if pain levels are higher. Remember, stool softeners are mandatory if narcotics are given.
  • Monitor compartments frequently. If a cast is used, check the distal part of the extremity for pain, unwillingness to move, numbness or swelling. If any are present, call the physician or extender and expect prompt attention to the problem.
  • Always think about the possibility of abuse. Fractures are rarely seen in children under 3, and almost never if less than 1 year old. If you have concerns about the physical findings or parent interactions, let the physician and social workers know immediately.