Category Archives: General

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

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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.

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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. 

Related posts:

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Trauma Activation Patients Staying Too Long In Your ED?

One of the long-held beliefs in trauma care relates to the so-called “golden hour.” Patients who receive definitive care promptly do better, we are told. In most trauma centers, the bulk of this early care takes place in the emergency department. However, for a variety of reasons, throughput in the ED can be slow. Could extended periods of time spent in the ED after patient arrival have an impact on survival?

Wake Forest looked at their experience with nearly 4,000 trauma activation patients who were not taken to the OR immediately and who stayed in the ED for up to 5 hours. They looked at the impact of ED dwell time on in-hospital mortality, length of stay and ventilator days.

Overall mortality was 7%, and the average time in the ED was 3 hours and 15 minutes. The investigators set a reasonable but arbitrary threshold of 2 hours to try to get trauma activation patients out of the ED. When they looked at their numbers, they found that mortality increased (7.8% vs 4.3%) and that hospital and ICU lengths of stay were longer in the longer ED stay group. Hospital mortality increased with each hour spent in the ED, and 8.3% of patients staying between 4 and 5 hours dying. ED length of stay was an independent predictor for mortality even after correcting for ISS, RTS and age. The most common cause of death was late complications from infection.

Why is this happening? Patients staying longer in the ED between 2 and 5 hours were more badly injured but not more physiologically abnormal. This suggests that diagnostic studies or consultations were being performed. The authors speculated that the knowledge, experience and protocols used in the inpatient trauma unit were not in place in the ED, contributing to this effect.

Bottom line: This is an interesting retrospective study. It reflects the experience of only one hospital and the results could reflect specific issues found only at Wake Forest. However, shorter ED times are generally better for other reasons as well (throughput, patient satisfaction, etc). I would encourage all trauma centers to examine the flow and delivery of care for major trauma patients in the ED and to attempt to streamline those processes so the patients can move on to the inpatient trauma areas or ICU as efficiently as possible.

Reference: Emergency department length of stay is an independent predictor of hospital mortality in trauma activation patients. J Trauma 70(6):1317-1325, 2011.

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What The Heck Is It? Final Answer!

Yesterday, I posted the physical exam findings on this mystery object. A tiny puncture wound was present just to the right of the xiphoid on the lower chest wall, and a small sharp point was palpable.

Here’s how to deal with it:

Step 1. (Image 1) Don’t let it move or try to pull it out immediately! I didn’t want this thing to go in any further, or work it’s way out in case it was in the heart. I snapped a hemostat on the end of it for stabilization.

Step 2. (Images 2 and 3) Find out where it is exactly. You need to know what if any vital structures it may have pierced so you can plan for removal. In this stable patient, CT was the best option. If he had been unstable, it would have meant an immediate trip to the OR. Note how the object is within the chest wall, BUT it had penetrated at least as deep as the lung since a pneumothorax was present.

Step 3. (Image 4) Get it out! Off to the operating room for removal, just in case some unexpected bleeding or hemodynamic changes were to occur. After the patient was asleep, a chest tube was inserted. The object was a fine nail from a commercial nail gun mishap and pulled out easily with the hemostat. He was discharged two days later after the tube was pulled. 

Photo source: personal archive. Patient not treated at Regions Hospital

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