In the last post, I discussed what to do if your hospital is thinking about switching to an electronic trauma flow sheet (eTFS). Today I’ll give you some tips on what to do if the cat’s already out of the bag and it’s already been implemented.

The number one priority is to show the impact of the eTFS on the trauma program. This involves the same two components I’ve already written about:

1. Accuracy. The trauma program must measure the impact of the “garbage in” phenomenon on the performance improvement (PI) process. This is critically important, because bad data will decrease the quality of your PI analysis. For example, if the PI program is not able to determine that hypotensive patients are being taken to CT scan, patient harms could occur that are not detected. This could result in two bad things for your trauma program (and patients): unanticipated mortality, and deficiencies during a verification visit.
   Be on the lookout for extraneous or impossible data points. Keep a list of information that is consistently missing. Use all of this information to work with your hospital administration to find ways to make it better.
2. Efficiency.  Your program must also find a way to measure the efficiency of abstraction by the trauma program manager, PI coordinator, registrars, or whoever is tasked with doing it. Keep track of the time needed to abstract a trauma activation chart vs a non-activation. This will give you an idea of the extra time needed to process the eTFS data. Or just clock in when starting eTFS abstraction, and clock out when finished. The amount of time will probably astonish you.
   Monitor average days to completion of registry entries, and look at the number of cases not fully abstracted by 60 days to see if there is a noticeable impact on your registry concurrency. Delays here are common in centers with high volumes of trauma activations because the abstractors must spend an inordinate amount of time trying to pull information from the eTFS.

Once your hospital has taken the plunge and adopted the eTFS, it is very difficult to go back. Many centers are convinced that “this next update is going to make it so much better.” It never does! I have visited programs that have been tweaking their processes and reports for almost 8 years! None have been able to improve it significantly.

Your hospital administration will ultimately need to decide how to proceed, depending on how damaging the eTFS is to the trauma PI program and how much it will cost to continue to tweak it vs returning to a paper flow sheet. Good luck!

I’ve spent several posts showing you the major problems inherent in using an electronic trauma flow sheet (eTFS). It boils down to Garbage In / Garbage Out and time.  It costs a lot of money and weakens an otherwise robust trauma performance improvement process.

Here’s the real bottom line:

” A hospital using an electronic trauma flow sheet is paying a lot of money for a product that forces them to pay even more money for people to essentially transcribe inaccurate data back onto a paper trauma flow sheet.”

So what can be done about it? That depends on whether the eTFS has already been implemented. Today, I’ll discuss what to do if it’s still in the planning stages.

You’ve just heard that your hospital is considering switching to an eTFS. Here’s what you should do:

1. Warn everyone you can, loudly! Use all of the ammunition you’ve read about here. Talk to your administrative contacts. Ultimately, your CEO needs to hear the concerns.
2. Visit another hospital with similar trauma volumes using the same eTFS. Don’t just call them up and ask how it’s going. Go and visit, and watch during an actual trauma activation. How is the scribe doing? Can they keep up? Is there a “cheat sheet?” Then talk to the people who abstract the eTFS data. Ask how long it takes compared to the old days of paper.
3. Consider a test implementation, and have two scribes, one using the eTFS and one using a paper sheet. After each trauma activation, objectively compare scribe performance, accuracy, and completeness. The eTFS cannot be allowed until they are equivalent (which I have never seen).
4. During the test implementation, have two abstractors analyze the data, one using the eTFS and one using the paper sheet. How long does it take to find all pertinent demographics, sign-in times, primary survey, secondary survey/exam, procedures, vital signs flow, fluids & IVs, I&O? Was the patient hypotensive? What activities occurred during those times: procedures, drugs, CT scans? The eTFS cannot be allowed until they are equivalent (which I have also never seen).
5. Continue to work with your hospital administration, showing them this data. Hopefully, they will see the light and abandon this “great idea.” At least until the technology improves, which it hasn’t for the last ten years!

But what if they don’t? Or what if you’ve walked into a program already using it? I’ll talk about that in the next post on Friday.

In my last post, 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 also creates a garbage out situation.

There are two ways to view the eTFS on the back end (abstraction phase): read a paper report (timeline), 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. Ebola screens. Sepsis score. Many things that have nothing to do with trauam. They are difficult to understand, and it is very difficult to pick out the true “signal” due to all the “noise!” And it doesn’t matter how customized the report is, it will nearly 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 are 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. In the next post, I’ll discuss strategies to use if your hospital is “considering” moving to an eTFS. And next week, 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. 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.

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:

1. 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.
2. 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.