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Yet More On The EMR / Trauma Flow Sheet Debate

My opinions about using an electronic medical record (EMR) system for recording trauma activations are well known. I received this well thought out response that I wanted to share and comment on:

My quote: “I defy any of them to come to a trauma resuscitation and rapidly and accurately transcribe all of the information presented, or try to review a PI case based on a printed EMR report.”

Their response: I’m a nurse informaticist, I’ve been a trauma nurse for 15 years, and I review PI cases using the electronic record. I work in an inner city Level 1 trauma center that’s associated with a large academic institution. We have recently implemented an ED Information System in our department and I have documented major traumas electronically. My trauma charts beat my colleagues written flowsheet in accuracy, comprehensiveness, and detail, hands down.

Your blog entry on this topic seems very close-minded. The “flowsheet” is not the silver bullet for trauma documentation. I agree that an EMR can be lengthy but it, by far, surpasses the flowsheet in thoroughness in detail. They both have their pros and cons, why be so quick to pick one? Yes, flowsheet data might be convenient for the reviewer but have you considered the effect on workflow for the frontline staff? An ED that has a comprehensive information system (CPOE, electronic tracking, physician and nurse documentation) must pull out a piece of paper and write on it so that a reviewer can find things easier retrospectively? It seems to me the priority should be the appropriate care for the patient and positive outcomes versus a reviewer being inconvenienced by having to read a long chart.

My response: My main problem with using an EMR to record a trauma activation is that the current human interface technology (keyboard, mouse) do not allow for rapid data entry and movement between different screens of input boxes. If a scribe such as yourself becomes extremely familiar with the system, it is certainly possible to overcome these difficulties with sheer skill and familiarity. However, your response implies that you are the only one capable of doing this. Your colleagues must still use the written trauma flow sheet.

The purpose of the flow sheet is to allow any scribe to record meaningful data that can be used to document patient care and to review and rebuild a complex resuscitation for performance improvement purposes. It is not designed to please trauma center reviewers. But the process the reviewers use to reconstruct a trauma activation is the same one that the hospital’s trauma program must use to dig into the events that occur in a trauma activation. If the input data is faulty because the scribe could not keep up in the EMR or had to enter it later, or if the output is dozens of pages of data that is difficult to sift through, the trauma program manager must spend an inordinate amount of time trying to figure out exactly what happened. The “thoroughness and detail” you mention in the EMR can be a hindrance if the quantity of data eclipses its quality. I have reviewed EMR records with 30 pages in the trauma flow sheet report!

The reviewers look for some kind of trauma flow data that they can use to rapidly rebuild what happened in the trauma room. If the reviewers can’t do it, then the trauma program probably can’t do it either. Neither I nor any of the other reviewers I have worked with have found an EMR trauma flow sheet that matches the utility of paper. Yet. The day will come, but it’s not here yet.

I welcome any additional opinions on this debate. Please leave a comment!

Related posts:

Once Again: Trauma Flow Sheets vs the Electronic Medical Record

There’s been renewed interest among my readers regarding trauma flow sheets and the EMR. This is an update on information from a previous post.

There is a continuing push by hospital administrations nationwide to move toward the use of electronic medical record (EMR) systems in hospitals. In the US, much of this is being driven by the Meaningful Use initiative by CMS. There are a number of benefits from using such systems, including but not limited to:

  • Comprehensive and permanent data collection
  • Easily accessed system-wide
  • Reduction in human errors
  • Increased throughput once the initial learning curve has been completed
  • Multifaceted reporting capabilities

Unfortunately, many hospitals or hospital system IT departments are insistent in moving all charting to the EMR, including the trauma flow sheet. For some, it is a revenue enhancement tool that takes advantage of improved documentation by ED physicians. For others, it is a result of the irrational urge to make everything paperless.

As a trauma center reviewer, I have had the privilege of visiting many hospitals and inspecting their trauma flow sheet charting tools. The bottom line is that I have still not found an electronic medical record system that can replace the handwritten trauma flow sheet.

A trauma team activation is a complex, fast-paced, finely orchestrated performance that does not lend itself well to being recorded electronically. There are two major problems:

  • Accurate and timely data entry (human interface issue: mouse, keyboard)
  • Intelligible reports (report organization problem)

There is so much information being transferred nearly simultaneously (vital signs, physical findings, procedures, fluid volumes given, laboratory and radiology orders, narratives) that it is not possible to record it completely and accurately using any current computer data entry interface or medical record system. Frequently, it ends up being recorded by hand on another piece of paper and is then entered later into the EMR. This is easily spotted by trauma reviewers.

The reporting features of virtually all EMRs allow for a listing of events sorted one way or another. It is rarely graphical in nature, and typically spans many, many pages of text output. Charts that I have reviewed have “reports” ranging from 8 to 20+ pages. It is virtually impossible for a human being to read through this type of output and reconstruct the flow of a trauma resuscitation. In many PI review cases, the trauma program manager is reduced to transcribing the individual data items from the EMR back onto a paper trauma flow sheet in order to conceptualize the resuscitation. Frequently, trauma reviewers identify care problems during the trauma activation that were buried in all the report output.

IT personnel may claim that the problem is an “end user failure.” It’s not. I defy any of them to come to a trauma resuscitation and rapidly and accurately transcribe all of the information presented, or try to review a PI case based on a printed EMR report.

The real bottom line: trauma flow sheets (and other similar code sheets) can not and should not be reduced to electronic data entry. It is not only frustrating, but will hamper the trauma PI process. If the reviewers find that the impact on the trauma PI program is significant, it may result in a PI criterion deficiency and can jeopardize a trauma center’s verification status!

Related post:

Why Do Trauma Patients Get Readmitted?

Readmission of any patient to the hospital is considered a quality indicator. Was the patient discharged too soon for some reason? Were there any missed or undertreated injuries? Information from the Medicare system in the US (remember, this represents an older age group than the usual trauma patient) indicates that 18% of patients are readmitted and 13% of these are potentially preventable.

A non-academic Level II trauma center in Indiana retrospectively reviewed their admissions and readmissions over a 3 year period and excluded patients who were readmitted on a planned basis (surgery), with a new injury, and those who died. This left about 5,000 patients for review. Of those, 98 were identified as unexpected readmissions. 

There were 6 major causes for readmission:

  • Wound (23) – cellulitis, abscess, thrombophlebitis. Two thirds required surgery, and 4 required amputation. All of these amputations were lower extremity procedures in obese or morbidly obese patients.
  • Abdominal (16) – ileus, missed injury, abscess. Five required a non-invasive procedure (mainly endoscopy). Only 2 required OR, and both were splenectomy for spleen infarction after angioembolization.
  • Pulmonary (7) – pneumonia, empyema, pneumothorax, effusion. Two patients required an invasive procedure (decortication, tube placement).
  • Thromboembolic (4) – DVT and PE.  Two patients were admitted with DVT, 2 with PE, and 1 needed surgery for a bleed due to anticoagulation.
  • CNS (21) –  mental status or peripheral neuro exam change. Eight had subdural hematomas that required drainage; 3 had spine fractures that failed nonoperative management. 
  • Hematoma (5) – enlargement of a pre-existing hematoma. Two required surgical drainage.

About 14% of readmissions were considered to be non-preventable by a single senior surgeon. Wound complications had the highest preventability and CNS changes the lowest. Half occurred prior to the first followup visit, which was typically scheduled 2-3 weeks after discharge. This prompted the authors to change their routine followup to 7 days. 

Bottom line: This retrospective study suffers from the usual weaknesses. However, it is an interesting glimpse into a practice with fewer than the usual number patients lost to followup. The readmission rate was 2%, which is pretty good. One in 7 were considered “preventable.” Wounds and pulmonary problems were the biggest contributors. I recommend that wound and pulmonary status be thoroughly assessed prior to discharge to bring this number down further. Personally, I would not change the routine followup date to 1 week, because most patients have far more complaints that are of little clinical importance than compared to 2 weeks after discharge.

Reference: Readmission of trauma patients in a nonacademic Level II trauma center. J Trauma 72(2):531-536, 2012.

Cognitive Rest??

One of the more commonplace recommendations for recovery from mild traumatic brain injury (TBI) is “cognitive rest.” Sports medicine professionals recommend it, physiatrists recommend it, and trauma professionals talk about it.

First, what is it, exactly? I’ve seen a number of descriptions, and they vary quite a bit. The main concept is to avoid all activities that involve mental exertion. This includes using a computer, watching TV, talking on a cell phone, reading, playing video games, and listening to loud music. Huh?

What good does this allegedly do? Most articles that I’ve read theorize that cognitive activity somehow increases the metabolic activity of the brain and that this is bad. One of the more interesting papers I read (from 2010!) says it best: “It is now well-accepted that excessive neurometabolic activity can interfere with recovery from a concussion and that physical rest is needed.”

Read carefully. Well-accepted. The paper cites unpublished data on children by one of the authors, 2 meta-analyses and 2 consensus opinions. In other words, no data at all. Yet somehow the concept has caught on.

First of all, I don’t think it’s possible for most people to realistically practice cognitive rest. Who knows if there is really any difference in metabolism and energy use by the brain if you are engaging in any of the banned activities above? And let’s go to the other extreme: if one lies quietly in bed meditating, shouldn’t this be the ultimate cognitive rest? Yet fMRI and PET studies suggest (also limited data) that cerebral flow in specific areas of the brain increases during this state.

Maybe a modest increase in activity is good. Physical activity (within limits) has been shown to be very beneficial to physical and psychological well being time and time again. And the only paper I could find on the topic with respect to TBI showed that randomization to bedrest vs normal physical activity had no difference in post-concussive syndrome incidence or severity. However, the active group recovered with significantly less dizziness.

Bottom line: There is no data to support the concept of cognitive rest. Any type of activity, either mental or physical, can cause fatigue in a variable amount of time in people with mild TBI. It is probably best to interpret this as a signal to take it easy and recover for a while before exerting oneself again. But so far there is no objective data to show that cognitive activity either helps or hinders recovery.

References:

  • Cognitive rest: the often neglected aspect of concussion management. Athletic Therapy Today, March 2010, pg 1-3.
  • Effectiveness of bed rest after mild traumatic brain injury: a randomised trial of no versus six days of bed rest. J Neurol Neurosurg Psychiatry 73:167-172, 2002.

The Future of the Medical Journal – Part 2

After posting yesterday, I was informed that LWW was not the first to enter the small screen arena. The British Medical Journal (BMJ) released content for the iPad platform beginning in December 2011. This journal uses the built-in Newsstand app on the iPad or iPhone.

On first look, it appears to be more robust than the LWW app for Neurosurgery. The BMJ allows access to other related content streams, such as their news, blogs, podcasts and video. It is a bit more interactive and does allow searching and bookmarking.

Bottom line: I’m sure someone will step forward with yet another earlier entry into the smartphone/tablet arena. Regardless, it’s all good. Either Newsstand or independent app works, although the Newsstand offers some pre-built functionality for developers that might make it a bit easier to create. However, the Newsstand is also Apple-specific, and won’t work for all the people with Android or Windows based phones and tablets who will be screaming for this content.

Reference: search for “BMJ” in the Apple App Store