Yesterday, I wrote about how the electronic trauma flow sheet (eTFS) practically assures a garbage in situation. Today, I’ll dig into what happens on the back end, and how it creates a garbage out situation.

There are two ways to view the eTFS on the back end (abstraction phase): read a paper report or view it live in the electronic health record (EHR). Let’s look at each:

• Paper report. Anyone who has actually generated one of these can tell you that it’s a disaster! Reams of paper, typically 20-30 pages. Hundreds of “chronological” entries. Inclusion of extraneous information from later in the hospital stay. Difficult to understand. Hard to pick out the true “signal” due to all the “noise!” And it doesn’t matter how customized the report is, it will always fail on these issues.
• Live EHR. Your abstractor (registrar, PI coordinator, trauma program manager) logs in and pulls up the screen(s) containing the eTFS. Once again, they need to mouse and keyboard around, looking for the specific things they are interested in. Piece by piece, they try to assemble a human-understandable picture of what happened. But since it’s not chronological across all activities in this view, it can be very challenging.
• Both. And then there’s the issue of Garbage In I discussed yesterday. Conflicting patient arrival times. Lack of accurate team arrival documentation. Vital signs and IV infusions recorded after patient expiration or discharge. No massive transfusion start time. Inaccurate data from the scribe’s “cheat sheet.”

The final result of all of the shortcomings listed above is this: it increases trauma flow sheet abstraction time by three-fold or more! If you are a trauma center with a two tier trauma activation system, you probably have a lot of TTAs. Therefore, it takes a lot of time to abstract all those flow sheets. Which ultimately means that you (this really means your hospital) will have to pay for more registrars / PI coordinators / nurses!

Hopefully, I’ve convinced you that the eTFS is not a great way to go. Tomorrow, I’ll discuss strategies to use if your hospital is “considering” moving to an eTFS. And Friday, I’ll wrap up with what to do if you’ve already been burdened with it.

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. Beginning prior to patient arrival, 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. Some are simultaneous.

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

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 common 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, between computer workstations?

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