All posts by TheTraumaPro

New Developments On Distracted Driving

The Governors Highway Safety Association released a study that sifted through 350 scientific papers dealing with distracted driving. They summarized their analysis in a nice report that can be downloaded here.

There are 4 types of distraction:

  • Visual – looking at something other than the road
  • Auditory – listening to something not related to driving
  • Manual – manipulating something other than the steering wheel
  • Cognitive – thinking about something other than driving

Smart phones provide all four modalities! About two thirds of drivers report using a cell phone while driving, and 7-10% were observed to be using one at any given time. About 12% of drivers admit to texting while driving, and about 1% of drivers are texting at any given time. At least one driver is reported to be distracted in 15-30% of car crashes. 

The following items were gleaned from the papers reviewed:

  • Cell phone use increases crash risk, but the exact amount is not known
  • Hands-free cell phone use has not been shown to be safer
  • Texting increases crash risk, but the exact amount is not known
  • Hand-held phone bans reduce use somewhat
  • Texting bans have not shown any significant effect, although high visibility enforcement campaigns offer some hope

Syracuse NY and Hartford CT enacted high visibility campaigns (“Phone in one hand, ticket in the other”) in late 2010 and spring 2011. They found that cell phone use dropped by half, and texting dropped 72% in Hartford and 32% in Syracuse. These results do not agree with the GHSA findings, most likely because of the intensity of the efforts in these two cities. 

Bottom line: We all know that texting while driving is bad and cell phone discussions while on the road are not very good either. There may be some utility to enacting bans on these activities. However, given the other responsibilities of our police departments, enforcement will always be a lower priority. Engineering solutions like roadway rumble strips can help divert attention back to driving, and crash investigations should aggressively examine any contributions to driver distraction. Ultimately, we’re going to have to treat this problem like we do for driving while intoxicated, with stiff penalties and driving restrictions. Unfortunately, I don’t think we’ve got the fortitude to do it anytime soon.

Download: GHSA Report on Distracted Driving

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More On The EMR / Trauma Flow Sheet Debate

I’ve posted several times regarding my opinions about using an electronic medical record (EMR) system for recording trauma activations. Yesterday, I received a well thought out response that I wanted to share and comment on:

“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.”

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 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. 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 they 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 post: Trauma flow sheets vs the electronic medical record and the comment below it

ACS Review Dinner Tip: Signage

The ACS Review Dinner is an important part of gathering information on your trauma program. Many of the principal players in your program are present, and the reviewers will have specific questions for most. Although the reviewers may meet many informally before dinner begins, it may be difficult to keep all the names and titles straight.

Good signs at the table are very helpful. Here are key points on providing the best signage possible:

  • The sign must be large. Compare the size of the sign in the photo to the 8.5×11 inch document next to it.
  • The font size should be large. This allows the reviewers to read name and title from across the room.
  • The same information should be on both sides. Everyone can see their own name so they know where to sit without turning every sign around.

The sign in the photo is a perfect example of what a good placeholder should look like.

Motorcycle Helmet Law Tragedy

I’ve written about motorcycle helmet laws in the past, and the research that supports their use. Unfortunately, not everyone buys into others telling them about the safety aspects. This article hit the news wires on Sunday:

ONONDAGA, N.Y. – Police say a motorcyclist participating in a protest ride against helmet laws in upstate New York died after he flipped over the bike’s handlebars and hit his head on the pavement.

The accident happened Saturday afternoon in the town of Onondaga, in central New York near Syracuse.

State troopers tell The Post-Standard of Syracuse that 55-year-old Philip A. Contos of Parish, N.Y., was driving a 1983 Harley Davidson with a group of bikers who were protesting helmet laws by not wearing helmets.

Troopers say Contos hit his brakes and the motorcycle fishtailed. The bike spun out of control, and Contos toppled over the handlebars. He was pronounced dead at a hospital.

Troopers say Contos would have likely survived if he had been wearing a helmet.

The bikers objected to laws that would require them to wear a helmet while riding. This was the organizer’s reaction to the death:

Christinea Rathbun, president of the Syracuse ABATE chapter, said the biker’s death would not affect the group’s stance on helmet laws. "Absolutely not,“ she said. "It’s not going to stop us protesting our right to wear a helmet or not wear a helmet. It’s your own risk.”

I understand that some riders want the ability to choose whether to wear their helmet. However, I have a hard time believing that Mr. Contos woke up that morning and would have chosen to forego wearing his helmet knowing that he would die later that day if he did. 

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Where is YOUR Personal Protective Equipment (PPE)?

Standard or universal precautions are essential in trauma. They serve two purposes: keeping you safe from exposure to body fluids, and keeping you from contaminating any open wounds. Unfortunately, they are not used as “universally” as they should be.

I’ve heard a number of excuses for not wearing them:

  • I don’t have time to put them on
  • They’re so hot!
  • It’s just a kid, I have nothing to worry about

All wrong! It takes less than 30 seconds to put them on. And yes, they may be a little warm, but if you have time to notice, then your trauma activations are taking too long. Anyone, including children, may have diseases you don’t want to share.

There are two major reasons that are legitimate and must be addressed:

  1. They are not conveniently placed. The deeper in the trauma room they are, the less likely anyone is to wear them (see photo). Place them just outside the door to your trauma bay in plain sight.
  2. Their use is not enforced. Assign specific people the role of PPE police. Emergency physicians and surgeons are optimal, but the charge nurse or others in authority positions are fine.

Develop a culture where the expectation is that everyone who enters the trauma bay, no matter what their rank, must be wearing their protective gear. Your philosophy should be “it’s not just a good idea, it’s the law.”