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

July 10, 2023 The Trauma Pro Leave a comment

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. Before the patient arrives, 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. Several are simultaneous.

This stream of information continues after the patient leaves the trauma bay for CT, imaging, interventional radiology, operating room, ICU, or floor bed. The flow sheet scribe is charged with recording all of this information as contemporaneously as possible. This ensures the 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 laid out before the scribe. All data blocks are readily visible and are grouped in logical clusters: prehospital information here, primary survey data there, procedures in that one, vital signs and narrative there. They are equally and immediately accessible for input.

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 widespread 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 and between computer workstations?

During chart reviews, I have seen numerous examples of fluids, vital signs, and drug administration recorded well after the patient has been declared dead!

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

Technology

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

June 30, 2023 The Trauma Pro Leave a comment

Today, I’ll kick off my series on the use of the electronic trauma flow sheet (eTFS). The biggest question is, why does your hospital want you to use it?

Typically, hospital administrators pressure trauma programs to adopt an eTFS at some point after implementing the hospital-wide use of an electronic health record (EHR). When I started this series nearly 15 years ago, many hospitals still used paper charting. But now, in 2023, virtually every trauma center uses one of the major brands of EHR.

The trauma programs had been using paper trauma flow sheets for decades. They were intuitive, information was laid out in logical blocks, and every data point on the entire sheet could be located and written within a second. Of course, data accuracy could always be a problem, but this usually boiled down to a scribe experience issue and could be remedied with training and feedback.

Initially, the major EHR makers did not have an eTFS product. Epic Systems became the first, and hospital administrators eventually became aware of it. Slowly they began to insist that their trauma programs switch to it.

But why? For the most part, they gave two reasons:

We need to go paperless! The assumption was that, since the rest of the charting would be electronic, the trauma flow sheet should also be moved to this format. Just to be consistent, I guess.
The reality is that there will always be some good, old-fashioned paper parts to the patient’s chart. Every hospital floor has a little cubby somewhere with old-timey three-ring binders for each patient to house the various 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. But not right away.
There is no reason a paper trauma flow sheet can’t also be scanned. At some point. The critical move is that it should be scanned early so that it is available in the EHR as soon as it is complete. A best practice would be to scan (or copy) the paper trauma flow sheet just before the patient leaves the emergency department for good so an interim version can be placed in the EHR. Once the patient arrives at their final hospital area (ICU, floor, etc.), a final scan can be made, and the paper copy placed in the old-timey binder.
We need to see patient care flow, vitals, meds, blood, etc., from the time they hit the door. We don’t want to miss any activity or trends that start 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 activity level. 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 the hospital stay.
But having said that, it is helpful to see all the medications and blood given during a hospital stay. Ideally, someone should reconcile the medications and blood products after the fact.

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

In my next two posts, I’ll write about why the eTFS doesn’t work well during the trauma resuscitation phase of care.

Performance Improvement

An Update On The Electronic Trauma Flow Sheet

June 27, 2023 The Trauma Pro Leave a comment

It’s been five years since I published my series on the use of the electronic trauma flow sheet (eTFS). Anyone who knows me is familiar with my skepticism about this tool. I’ve been writing about the significant problems it can create since 2008! With the progress in computing power and interfaces we have enjoyed, we would have this problem solved by now.

But alas, that is not the case. There has been little progress and at great expense and aggravation for the trauma centers. Since I last published the series, I’ve visited numerous hospitals that use the eTFS and a diminishing number that have stuck with the paper trauma flow sheet. Based on this experience, I am updating the series and will republish it here over the next several weeks.

As you read each part of the series, please take a moment to post comments or questions at the end of the piece or email them to me. I will strive to address them in my updates. And I would love to hear your opinions on how this tool is working (or not) for you. If I receive enough comments, I’ll post a summary of them at the end of the series.

I’ll kick off the series with my next post, which describes why your hospital wants you to switch to some newfangled eTFS. Enjoy, or weep, as the case may be!

General

Nursing Malpractice: The Basics – Part 2

June 23, 2023 The Trauma Pro Leave a comment

What are common sources of malpractice complaints against nurses? The most common event is medication error. Most people worry about common errors like wrong dose, wrong drug, and wrong route of administration. But one less commonly considered drug-related responsibility is assessment for side effects and toxicity of medications administered.

Other common reasons include failure to adequately monitor and assess the patient, and failure to supervise a patient that results in harm. Significant changes in patient condition must be reported to the responsible physician. However, doing so does not necessarily get the nurse off the hook. If the physician’s response leads the nurse to believe that they have misdiagnosed the problem or are prescribing an incorrect drug or course of action, the nurse is obligated to follow the chain of command to notify a nursing supervisor or other physician of the event.

And finally, one of the most common issues complicating malpractice cases of any kind is documentation. Lawsuits must typically be filed within two years of the event that caused harm. Once that occurs though, several more years may pass before significant action occurs. Collection and review of documentation, identification of experts, and collection of depositions takes time. And unfortunately, our memories are imperfect after many years go by. Good documentation is paramount! “Work not documented is work not done,” I always say. And poor documentation allows attorneys to make your good work look as bad as they want and need it to.

Reference: Examining Nursing Malpractice: A Defense Attorney’s Perspective. Critical Care Nursing 23(2):104-107, 2003.

General

Nursing Malpractice: The Basics – Part 1

June 20, 2023 The Trauma Pro Leave a comment

Back in the old, old days, there was really no such thing as nursing malpractice. Nurses had little true responsibility, and liability largely fell to the treating physicians. But as nursing responsibilities have grown, they have become an integral part of the assessment, planning, and management of their patients.

As all trauma professionals know, our work is very complex. And unfortunately, our understanding of how the human body works and responds to injury is still incomplete. So, unfortunately, undesirable things happen from time to time.

But does every little adverse event or complication mean that someone is at fault? Or that they can/should be sued? Fortunately, the answer is no.

The law is complex, at least to professionals outside the legal field. Following are the basics of malpractice as it relates to nurses.

There are four elements that must be present for a malpractice case to be brought forward:

The nurse must have established a nurse-patient relationship. Documentation provided by the nurse or other providers in the medical record must demonstrate that they were in some way involved in care of the patient.
A scope of duty must be established within the relationship. For example, an ICU nurse will have duties relating to examining the patient, recording vital signs, reporting significant events to physicians, etc. The exact duties may vary somewhat geographically and even between individual hospitals. Written policies help to clarify some of these duties, but often, experts are required to testify to what the usual standards of care are when not covered by policy.
There must be a departure from what is called “good and accepted practice.” The definition of this leaves a lot of wiggle room. It is defined as the care that an ordinarily prudent nurse would have provided in the given situation. It does not need to be the optimum or best care. And if there is more than one approved choice, a nurse is not negligent if they choose either of them, even if it later turns out to be a poorer choice.
Finally, there must be a cause-effect relationship between the nurse’s action and the patient’s alleged injury. This linkage must be more than a possibility, it must be highly probable. For example, wound infections occur after a given percentage of operations, and it varies based on the wound classification. It’s a tough sell to bring suit for improper dressing care in a grossly contaminated wound that is likely to become infected anyway. Typically, expert witnesses must attest to the fact that the patient was, more likely than not, harmed by the nurse’s action or inaction.

Tune in to my next post for Part 2 of Nursing Malpractice!

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