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Trauma Registry: The Nuts & Bolts of Data Collection. Karla Bryan, RN, BSN Trauma Coordinator EIRMC. Trauma Resuscitation Overview. Report received from EMS; trauma page goes out Pt. arrives in ED

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Trauma registry the nuts bolts of data collection

Trauma Registry: The Nuts & Bolts of Data Collection

Karla Bryan, RN, BSN

Trauma Coordinator

EIRMC


Trauma resuscitation overview
Trauma Resuscitation Overview

  • Report received from EMS; trauma page goes out

  • Pt. arrives in ED

  • Met by resuscitation team: at least 2 MDs, 2 RNs, Lab, X-ray, Respiratory Therapist, Pharmacist, Scribe, House Supervisor, Social Services, Security, CT Tech, EMS

  • Assessment, stabilization, procedures, tests (plain films/CT, angio, FAST)


What precludes thorough data collection
What precludes thorough data collection?

The Trauma Bay Environment

  • Recorder: Primary RN or dedicated recorder

  • The number of trauma team members in the room

  • Intense team activity: assessment, stabilization, diagnostics

  • Charting after the fact


Recording extremes
Recording Extremes:

  • Difficult: Pt. arrives from MVC, ejected, comatose, obvious open femur fx, open tib/fib fx, distended abdomen, respiratory distress

  • Easy: Pt. arrives after being bucked off horse, c/o sore back, obvious forearm fx, no neuro deficits, VSS, alert/oriented.


Getting the necessary information
Getting the Necessary Information

  • Know what you need

    ITR, ACS, NTDB

  • Look in depth at ED chart for needed data elements

  • Take information to your director

  • Meet with ED Director/Manager: be prepared to show ITR requirements, what is lacking on chart (if cues aren’t there, info won’t be collected)

  • Work with core group of ED RNs to revise chart to get required data elements


ED staff meetings:

  • Describe the purpose of the registry

  • Describe the needed data elements

  • Ask staff for ideas of how best to collect needed data elements (buy-in)

  • Describe how data can/will be used— can benefit them for presentations they do in the community/hospital


ED staff meetings: continued

  • Describe necessity of accurate data collection for PI purposes

    Examples:

    Physician timeliness— ACS requirement

    . (Our solution- team members

    names on glass trauma doors)


TS Timeliness L1/L21st-2nd Q 2006 (n =93)

  • Per review of nursing documentation only.


TS Timeliness L1/L21st-2nd Q 2006 (n = 90)

  • Per review of nursing documentation only.

  • 3 cases > 15 mins.


PI examples for ED staff meeting cont.

Triss: Need ISS, RTS (systolic BP, RR, GCS), Age, Blunt/Penetrating

Appropriateness of Activation: without documentation of mechanism, injuries, unable to determine


Appropriateness of activations all 1 st 2 nd q 2006
Appropriateness of Activations ALL1st-2nd Q 2006

(n=465)

ACS EXPECTED RATE

Under triage 5-10% Over triage 30-50%


Appropriateness of activations l1 1 st 2 nd q 2006
Appropriateness of Activations L11st-2nd Q 2006

(n=23)


Appropriateness of activations l2 1 st 2 nd q 2006
Appropriateness of Activations L21st-2nd Q 2006

(n=75)


Appropriateness of activations l3 1 st 2 nd q 2006
Appropriateness of Activations L31st-2nd Q 2006

(n=367)


Data abstraction entry
Data abstraction/entry

  • Don’t guess-if the information isn’t documented, mark as unknown

  • Check your abstraction form for missing data elements and do your data entry before you return the chart to medical records

  • Remember—garbage in, garbage out. Check your data against other reports

  • Continue to update nurses on what’s missing from documentation

  • Use your data: Report to ED, QI Dept, Physicians, Administration, Others


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