Tag Archives: Trauma flow sheet

New technology

When Did The Surgeon Arrive At The Trauma Activation?

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All trauma centers have mandatory arrival requirements for the surgeon at their highest-level trauma activations. Most Level I and II centers abide by the American College of Surgeons (ACS) requirement of 15 minutes after patient arrival. Level III centers typically mandate 30 minutes for their highest-level activation. And failure to meet these criteria can actually lead to loss of verification.

But what is the best way to record this critical piece of information? A number of methods have been used over the years. The earliest was simply recording the time of surgeon arrival on the paper trauma flow sheet. This has evolved over the years as technology has advanced. Most hospitals have installed badge swipe systems, since name badges have become nearly ubiquitous for gaining access to restricted areas within the hospital. A paper published last year details one hospital’s experience using a badge swipe system to do just this.

A NYC metro area Level I center started using a name badge swipe system to record the surgeon’s arrival in the ED for trauma activations several years ago. They examined their trauma activation data over a 7 month period at the end of 2016. Surgeon arrival times were recorded on the trauma flow sheet, and the electronic swipe information was included to supplement flow sheet results.

Here are the factoids:

  • There were 531 trauma activations during the study period, with 50 highest-level activations and 481 limited activations
  • The overall paper trauma flow sheet completion rate was 50% without card swipe data (!!)
  • For highest-level activations, surgeon presence was documented in 76%, but they arrived on time (< 15 minutes) only 70% of the time (!!!)
  • For intermediate-level activations, surgeon arrival was recorded 47% of the time and the surgeon was on time 45% of the time (I’m running out of exclamation points!!)
  • After including the badge swipe data, overall completion rate “improved” to 70%, which broke down to 90% in highest-level and 68% in the intermediate level activations
  • Surgeon compliance with arrival times improved to 84% and 63% for the two activation levels

The authors blamed the poor record keeping and compliance on “the fast pace of an ED.” They concluded that the badge swipe system was successful in increasing documentation and arrival compliance.

Bottom line: Oh, this is a fail on so many levels! First, surgeon arrival timeliness was appalling both with and without the badge swipe data. It started at 50% and increased to a barely passing score of 84%. And since this center only receives 100 highest-level activations per year, just a few more slip-ups could easily result in their loss of Level I verification. The increase in arrival compliance after adding badge data could be due to better documentation or better response because the surgeon knew they were being watched (Hawthorne effect).

Obviously, there are many reasons for documentation problems. The surgeon may have, indeed, been late. The scribe may not have been paying attention, or forgot to write the time in because things were busy. The flow sheet could be poorly designed, or worse, electronic.

The addition of technology to overcome human limitations is not the panacea many think it is. First, it’s expensive, especially if new gadgets are being purchased. In this case, it’s the same card swipe technology that is already present in the hospital. So there’s no additional cost in this case.

But it is always more work for some of the humans involved. Card swipe systems do not automatically integrate with a trauma flow sheet, even an electronic one. So some poor human will be tasked with getting the badge swipe report from security. Then, they will have to pore over the myriad card swipes and match the activation times to the data seen on the report. This can be time consuming in a busy ED.

I am still a big believer in personal responsibility. The key players, namely the surgeons, need to feel responsible for reporting their arrival time as a statistic vital to verification of their center. Only when they actually do, and this becomes part of the culture of the entire trauma team, will documentation and compliance approach perfection!

Reference: Implementation of a Radio-frequency Identification System to Improve the Documentation and Compliance of Attending Physicians’ Arrival to Trauma Activations. Cureus 10(11):e3582, 2018.

Technology

Electronic Trauma Flow Sheet – The Video!

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I’ve written a lot about the downside of the electronic trauma flow sheet. Well, a picture (or video in this case) is worth a thousand words!

I found a nice video on YouTube in which a nurse demonstrates some of the basic features of the Epic Trauma Narrator. As you watch, pay particular attention about the need for significant back and forth between mouse and keyboard, and the amount of scrolling necessary to get to all the various fields that need to be completed.

And keep an eye on the time. Now granted, the speaker has to slow down a bit to explain things. But if you look at how little gets entered in 8 minutes, you’ll get my point!

For those of you out there who have already adopted an electronic product, or are thinking about it, please leave comments here or Tweet your comments/questions!

YouTube player
Technology

The Electronic Trauma Flow Sheet: Oops! Now What Are My Options? Part 2

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Yesterday, 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. There are two components:

  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 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!

Technology

The Electronic Trauma Flow Sheet: Oops! Now What Are My Options? Part 1

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I’ve spent the last few days 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 the otherwise strong 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. Actually 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 scan? 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.”

But what if they don’t? Or what if you’ve walked into a program that is already using it? I’ll discuss that tomorrow.

General, Technology

The Electronic Trauma Flow Sheet: What Does(n’t) Work – Part 2

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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.