Category Archives: General

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!

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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!

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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.

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New Technology: Fracture Putty

Fracture healing takes a long time, as many of our patients can attest to. Six or eight weeks, and even more may be required for full healing. Researchers at the University of Georgia and in Houston have completed an animal study on rats using a type of “fracture putty” that dramatically speeds up this process. 

The researchers used adult mesenchymal stem cells that produce a protein which is involved in bone healing and regeneration. They created a gel using these cells, and injected them into the fracture sites which were stabilized externally (imagine a rat external fixator!). The fractures healed rapidly, and within 2 weeks the rats could run and stand on their legs normally.

Bottom line: The next step is to translate this work to larger animals. Strength and durability are major concerns. The amount of stress placed on rat legs and human legs is considerably different. If this pans out, it could revolutionize fracture healing, especially in cases where there may be highly disabling segmental bone loss (read: military). It will be several years before this can move to human studies.

Reference: University of Georgia Regenerative Bioscience Center

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Why Did The Trauma Team Cut Off My Clothes?

The fifth highest priority taught in the ATLS course is exposure. This generally means getting the patient’s clothes off so any hidden injuries can be identified. Early in my career, I was called to see a patient who had a gunshot to the chest that had been missed because the consulting physician had neglected to cut off her bra. A small caliber wound was found under the elastic strap in her left anterior axillary line after a chest xray showed a bullet in mid-thorax.

The usual trauma activation routine is to cut off the clothes. There are several tips and tricks we use to do this quickly. And a number of commercial products are out there to make it even easier.

But do we really need to cut everyone’s clothes off? I’m not disputing the fact that it’s important to be able to examine every square inch. But do we need to destroy everything our patient is wearing? I once saw a sequined wedding dress cut off (it’s almost as bad as cutting off a down jacket).

The answer is no. The key concept here is patient safety. Can you safely remove the clothing in a less destructive way? For most victims of major blunt trauma, we worry a lot about the spine. Unfortunately, it’s just not possible to allow the patient to wriggle out of their clothes and protect their spine. The same goes for fractures; it may be too uncomfortable to remove clothing because of fracture movement so scissors are required.

Penetrating trauma is a bit different, and in many cases it’s a good idea to try to get the clothing off intact. Once again, if spinal injury is a consideration (gunshots only), the involved clothes should be cut off. A patient with a gunshot to the chest can probably have their pants safely and gently pulled off, but their shirt and coat must be cut.

The police forensic investigators like to have intact clothing, if possible. This is another good reason to try to remove clothing from penetrating injury victims without cutting. 

Bottom line: Think before you cut clothes! Major blunt trauma and bad injuries require scissors. Lesser energy blunt injury may allow some pieces of clothing to be removed in the usual method. Most penetrating injury does not require cutting. But if you must (for patient safety), avoid any holes in the fabric so forensics experts can do their job.

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