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Trauma Documentation and Triage Resource Guide Educational Program 2004

The planning of the TEMSIS Project and Trauma Documentation

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Trauma Documentation and Triage Resource Guide Educational Program 2004

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    1. This is a Train-the-Trainer format – In EMS, we are all used to “See One, Do One, Teach One” In this presentation, we will be going through the slides to give you a feel for the general content AND ALSO talk about ways to present the information, additional resources, etc. **Go through contents of their packet/folder… **Discuss ways to use the material – classroom, self study…This is a Train-the-Trainer format – In EMS, we are all used to “See One, Do One, Teach One” In this presentation, we will be going through the slides to give you a feel for the general content AND ALSO talk about ways to present the information, additional resources, etc. **Go through contents of their packet/folder… **Discuss ways to use the material – classroom, self study…

    2. The planning of the TEMSIS Project and Trauma Documentation & Trauma Triage Educational Programs are funded in part by the United States Department of Health and Human Services, Health Resources and Services Administration – Trauma-EMS Grant Program. HRSA – H81MC00025-02-04

    3. Mission Statement To continuously improve our comprehensive statewide EMS system in order to ensure excellence of out of hospital emergency medical care to all persons within the state of New Hampshire. Our Mission Statement is what drives our actions. This program is one tool to help us meet our Mission.Our Mission Statement is what drives our actions. This program is one tool to help us meet our Mission.

    4. Introduction/Overview History of Trauma System Development Trauma Triage Trauma Documentation Data Collection and Utilization Approved Abbreviations Data Dictionary Green – the areas this power point will focus on primarily.Green – the areas this power point will focus on primarily.

    5. History of trauma system development Trauma triage steps, trauma communication, and transport decision making skills Improved use of the NH BEMS PCR History and utility of data collection Opportunities for improvement in data collection Documentation and data collection focus will be on the 17 Key Trauma Fields currently being tracked on a statewide level.Documentation and data collection focus will be on the 17 Key Trauma Fields currently being tracked on a statewide level.

    6. **The Resource Guide is undergoing some revisions, but will be available from the NHBEMS soon. - The Resource Guide contains more detailed resource information than this presentation. - This presentation contains the “Need to Know” information – items that are considered critical for all EMS providers in the state to be aware of.**The Resource Guide is undergoing some revisions, but will be available from the NHBEMS soon. - The Resource Guide contains more detailed resource information than this presentation. - This presentation contains the “Need to Know” information – items that are considered critical for all EMS providers in the state to be aware of.

    7. Saf-C 5902.07 Recordkeeping and Reporting “Recordkeeping and reporting shall be made by providing the information required by Saf-C 5902.08 and Saf-C 5902.09, as applicable…” using paper or electronic methods Saf-C 5902.08 PCR Form – Left Side Describes how to complete items on the left side of the PCR. Saf-C 5902.09 PCR Form – Right Side Describes how to complete items on the right side of the PCR. The New Hampshire Code of Administrative Rules describes “Recordkeeping & Reporting” requirements. Why are we having this discussion/class? *at this point in the class, the I/C can show the PCR - each section will be reviewed in detail later in the course.The New Hampshire Code of Administrative Rules describes “Recordkeeping & Reporting” requirements. Why are we having this discussion/class? *at this point in the class, the I/C can show the PCR - each section will be reviewed in detail later in the course.

    8. What is a Trauma System? An organized, coordinated effort in a defined geographic region that delivers a full range of care to all injured patients.

    9. Ideal Trauma System Components Injury Prevention EMS Field Intervention ED Care Surgical Interventions ICU Care Continued Hospital Care Rehabilitation Social Services Research & QI Green areas – will be the focus of this power point.Green areas – will be the focus of this power point.

    10. Trauma System Goal To get the right patient to the right hospital at the right time. Right Patient: Avoid over- and under-triage Right Hospital: Know hospital assignment & capability levels Right Time: Golden Hour & decreasing time to definitive careRight Patient: Avoid over- and under-triage Right Hospital: Know hospital assignment & capability levels Right Time: Golden Hour & decreasing time to definitive care

    11. Leading cause of death in people age 1-44 Especially males age 15-24 from MVCs Fourth leading cause of death overall MVCs in 2001: 3 million injuries and 42,000 fatalities Drinking is a factor in 49% of fatal MVCs GSWs: >40,000 fatalities per year Trauma Statistics – USA One of the most important factors that has positively influenced the morbidity and mortality of trauma patients during the last decade is the creation of Trauma Systems and air medical transport because the time from the accident to initiation of definitive care of the patient is the key to patient survivability. ** Traumatic injuries are the most preventable public-health problem today. (Done via education and enactment of laws/regulations.) These STATISTICS establish/verify the need for Trauma Systems One of the most important factors that has positively influenced the morbidity and mortality of trauma patients during the last decade is the creation of Trauma Systems and air medical transport because the time from the accident to initiation of definitive care of the patient is the key to patient survivability. ** Traumatic injuries are the most preventable public-health problem today. (Done via education and enactment of laws/regulations.) These STATISTICS establish/verify the need for Trauma Systems

    12. Death from Trauma - USA #1 MVC: 32.3% # 3 Falls: 9.3% # 2 Firearms: 22.2% (same 1,2,3 ranking as NH) Poisoning: 8.1% Drownings: 4.0% Burns: 4.1% Other: 20.2%#1 MVC: 32.3% # 3 Falls: 9.3% # 2 Firearms: 22.2% (same 1,2,3 ranking as NH) Poisoning: 8.1% Drownings: 4.0% Burns: 4.1% Other: 20.2%

    13. Leading cause of death in people age 1-34 MVCs Firearms Falls 5th leading cause of death overall 33% intentional 67% unintentional Someone in NH dies of trauma every 20 hours Trauma Statistics – NH 1st: MVC (inc. MVC, MCA, bicycles, pedestrian, etc.) 2nd: Firearms (87% suicides) 3rd: Falls (data from 1992-1996)1st: MVC (inc. MVC, MCA, bicycles, pedestrian, etc.) 2nd: Firearms (87% suicides) 3rd: Falls (data from 1992-1996)

    14. AN EXAMPLE of what a Trauma System can do/accomplish: 1 hour 45 minute extrication Camaro – high rate of speed on a rural road. No EtOH – lost control around a curve. Departed the roadway and hit a tree. +Seatbelt (his mom reminded him before he left the house) His friend was not wearing a SB and was ejected. Pronounced DOA on the scene. Air Medical helicopter called to the scene to assist with pt care during the extrication (PIVs, RSI, blood administration). Pt flown to Level I Trauma Center. 20 minute flight (1+ hour drive to Level I; 20 minute ride to Level III) Injuries: spleen, liver, pelvis fx, lower extremity fxs, required amputation below knee of left leg. Left the hospital ~ 2 weeks later. Very grateful for the care he received & the fact that he lived. AN EXAMPLE of what a Trauma System can do/accomplish: 1 hour 45 minute extrication Camaro – high rate of speed on a rural road. No EtOH – lost control around a curve. Departed the roadway and hit a tree. +Seatbelt (his mom reminded him before he left the house) His friend was not wearing a SB and was ejected. Pronounced DOA on the scene. Air Medical helicopter called to the scene to assist with pt care during the extrication (PIVs, RSI, blood administration). Pt flown to Level I Trauma Center. 20 minute flight (1+ hour drive to Level I; 20 minute ride to Level III) Injuries: spleen, liver, pelvis fx, lower extremity fxs, required amputation below knee of left leg. Left the hospital ~ 2 weeks later. Very grateful for the care he received & the fact that he lived.

    15. When Do Trauma Patients Die? 1. Immediate (>50%): Occur at the time of the injury and are generally a result of severe head or cardiovascular injury. The only possible intervention for this group is an aggressive prevention program through public awareness and education. (Concept of “preventable trauma” - you’ll notice that it is no longer called a “motor vehicle accident” ---it is now a “motor vehicle crash”…) 2. Early (30%): Occur during the first few hours following injury as a result of major torso or head injury. Many early deaths are preventable with appropriate care. The concept of the “Golden Hour” is derived from this group. 3. Late (15-20%): 2-4 weeks out. Occur as a result of infection or multisystem organ failure. Often due to inadequate initial resuscitation. Can potentially be affected by improvements in early care during the resuscitation phase. 1. Immediate (>50%): Occur at the time of the injury and are generally a result of severe head or cardiovascular injury. The only possible intervention for this group is an aggressive prevention program through public awareness and education. (Concept of “preventable trauma” - you’ll notice that it is no longer called a “motor vehicle accident” ---it is now a “motor vehicle crash”…) 2. Early (30%): Occur during the first few hours following injury as a result of major torso or head injury. Many early deaths are preventable with appropriate care. The concept of the “Golden Hour” is derived from this group. 3. Late (15-20%): 2-4 weeks out. Occur as a result of infection or multisystem organ failure. Often due to inadequate initial resuscitation. Can potentially be affected by improvements in early care during the resuscitation phase.

    16. Immediate death (over 50% of deaths) ON SCENE Patients die at the scene from: massive head and thorax injuries Reduction in mortality must occur through injury prevention: Drunk driving prevention; Seat belt/child safety seat usage; Motorcycle and bicycle helmet usage; Gun safety; Burn prevention Early death (approximately 30% of deaths) WITHIN A FEW HOURS Patients die within the first few hours from: central nervous system injury and hemorrhage Reduction in mortality is achieved with a systems approach and attention to the “Golden Hour”: Standardized patient care practice and rapid access to advanced life support; Standardized trauma triage and transport to an appropriate trauma care hospital; Immediate evaluation and resuscitation of all trauma patients in the ED by trained emergency or surgical personnel; Comprehensive intervention for major single-system and all multi-system trauma patients by experienced trauma surgeons; Utilization of a team approach with preplanned trauma response; Priority availability of all related hospital resources for the care of the injured patient (radiology, laboratory, blood bank, operating room, etc.) Late death (approximately 15% of deaths) WITHIN A FEW WEEKS Patients die days to weeks after injury from: sepsis or multiple organ failure Reduction in mortality involves the work of high-quality medical and nursing care on a 24-hour basis: Establishment of an intensive care unit dedicated to the needs of the critically injured adult and child; Specially trained physicians, nurses, and other allied health providers; Ongoing, continuing education for all professionals working in trauma care; Ongoing, continuous research into trauma prevention, pathophysiology, treatment, and outcomeImmediate death (over 50% of deaths) ON SCENE Patients die at the scene from: massive head and thorax injuries Reduction in mortality must occur through injury prevention: Drunk driving prevention; Seat belt/child safety seat usage; Motorcycle and bicycle helmet usage; Gun safety; Burn prevention Early death (approximately 30% of deaths) WITHIN A FEW HOURS Patients die within the first few hours from: central nervous system injury and hemorrhage Reduction in mortality is achieved with a systems approach and attention to the “Golden Hour”: Standardized patient care practice and rapid access to advanced life support; Standardized trauma triage and transport to an appropriate trauma care hospital; Immediate evaluation and resuscitation of all trauma patients in the ED by trained emergency or surgical personnel; Comprehensive intervention for major single-system and all multi-system trauma patients by experienced trauma surgeons; Utilization of a team approach with preplanned trauma response; Priority availability of all related hospital resources for the care of the injured patient (radiology, laboratory, blood bank, operating room, etc.) Late death (approximately 15% of deaths) WITHIN A FEW WEEKS Patients die days to weeks after injury from: sepsis or multiple organ failure Reduction in mortality involves the work of high-quality medical and nursing care on a 24-hour basis: Establishment of an intensive care unit dedicated to the needs of the critically injured adult and child; Specially trained physicians, nurses, and other allied health providers; Ongoing, continuing education for all professionals working in trauma care; Ongoing, continuous research into trauma prevention, pathophysiology, treatment, and outcome

    17. Organized Trauma Systems Result in: Reduced death & disability through: Injury Prevention System Planning Evaluation & Monitoring Communication/Collaboration/ Teamwork Reference articles provided in handout… Injury Prevention – public education System Planning – e.g. this class (trauma triage & transport, hospital assignment) Evaluation & Monitoring – QI process, loop closure Communication/Collaboration/ Teamwork - + working relationships Benefits of a successful Trauma System include: a reduction in deaths caused by trauma a reduction in the number and severity of disabilities caused by trauma an increase in the number of productive working years seen in America through a reduction in death and disability a decrease in the costs associated with initial treatment and continued rehabilitation of trauma patients a reduced burden on local communities as well as the Federal government in the support of disabled trauma patients a decrease in the impact of trauma on victims and their families. Reference articles provided in handout… Injury Prevention – public education System Planning – e.g. this class (trauma triage & transport, hospital assignment) Evaluation & Monitoring – QI process, loop closure Communication/Collaboration/ Teamwork - + working relationships Benefits of a successful Trauma System include: a reduction in deaths caused by trauma a reduction in the number and severity of disabilities caused by trauma an increase in the number of productive working years seen in America through a reduction in death and disability a decrease in the costs associated with initial treatment and continued rehabilitation of trauma patients a reduced burden on local communities as well as the Federal government in the support of disabled trauma patients a decrease in the impact of trauma on victims and their families.

    18. Cite studies here --- Reference articles in handout 50-60% of trauma deaths are preventable with a Trauma Care System (reference: 1999 Trauma Education Program) Thirty years of experience has brought much change to how Trauma Systems are organized. During this time, the focus has shifted from Trauma Centers to Trauma Systems, exclusive to inclusive systems, and categorization to designation of acute care facilities. One thing has remained steady regarding the benefit of Trauma Systems: organized Trauma Systems save lives. Findings from several studies indicate trauma mortality is reduced by 15-20% when the very seriously injured are treated at trauma centers versus non-trauma centers. It is estimated that 50-60% of trauma deaths are preventable with comprehensive trauma system implementation. Effects may take 10 years to be apparent due to: maturation and development of trauma triage protocols, interhospital transfer agreements, organization of trauma centers, and ongoing quality assurance.Cite studies here --- Reference articles in handout 50-60% of trauma deaths are preventable with a Trauma Care System (reference: 1999 Trauma Education Program) Thirty years of experience has brought much change to how Trauma Systems are organized. During this time, the focus has shifted from Trauma Centers to Trauma Systems, exclusive to inclusive systems, and categorization to designation of acute care facilities. One thing has remained steady regarding the benefit of Trauma Systems: organized Trauma Systems save lives. Findings from several studies indicate trauma mortality is reduced by 15-20% when the very seriously injured are treated at trauma centers versus non-trauma centers. It is estimated that 50-60% of trauma deaths are preventable with comprehensive trauma system implementation. Effects may take 10 years to be apparent due to: maturation and development of trauma triage protocols, interhospital transfer agreements, organization of trauma centers, and ongoing quality assurance.

    19. Trauma System Development: US WWII, Korea, & Vietnam War experiences Trauma Triage; reduced time to definitive care; better care, outcome, & survival than stateside civilian sector 1966 “White Paper” Identified trauma as a national health care problem A very quick review – more detail is available in the Resource Guide Vietnam experience (1966-1974): MASH units, rapid evacuation by helicopter, specialized training, improved communications resulting in more accurate triage to facilities that could handle specific injuries, delay to treatment – 65 minutes, mortality rate 1.7% (v. Korea: delay to Tx 2-4 hours, mortality 2.4%) 1966 Landmark Paper: “Accidental Death and Disability: The Neglected Disease of Modern Society” – recommended numerous improvements to trauma care.A very quick review – more detail is available in the Resource Guide Vietnam experience (1966-1974): MASH units, rapid evacuation by helicopter, specialized training, improved communications resulting in more accurate triage to facilities that could handle specific injuries, delay to treatment – 65 minutes, mortality rate 1.7% (v. Korea: delay to Tx 2-4 hours, mortality 2.4%) 1966 Landmark Paper: “Accidental Death and Disability: The Neglected Disease of Modern Society” – recommended numerous improvements to trauma care.

    20. Trauma System Development: US 1973: First Federal EMS Funding $ available for Trauma System development 1976: ACS COT Began to identify elements of a Trauma System Based on an Exclusive Trauma System model 1992: CDC first addresses concept of an Inclusive Trauma System model 1973: EMS Systems Act: identified 15 essential components of an EMS system. Federal funding was provided to state and regional EMS systems that modeled their system after the 15 components. This was also the first legislation to require data or documentation of EMS services through a coordinated patient care record and a formal review and evaluation process (now referred to as “QM”). “Exclusive Model” – only certain hospitals could see trauma patients “Inclusive Model” – realization that all hospitals will see and treat trauma patients. Therefore, all hospitals need to have the appropriate resources available to them.1973: EMS Systems Act: identified 15 essential components of an EMS system. Federal funding was provided to state and regional EMS systems that modeled their system after the 15 components. This was also the first legislation to require data or documentation of EMS services through a coordinated patient care record and a formal review and evaluation process (now referred to as “QM”). “Exclusive Model” – only certain hospitals could see trauma patients “Inclusive Model” – realization that all hospitals will see and treat trauma patients. Therefore, all hospitals need to have the appropriate resources available to them.

    21. Trauma System Development: NH 1980s: Exclusive Regional-Based Trauma System Each of the 5 Regions was asked to make Trauma Center designations Not successful 1992 & 1994: Inclusive Statewide Trauma System Plan Grants from HRSA In the early 1980s New Hampshire began to look at Trauma System development. Initial effort focused on creating a regional Trauma System that worked within the existing EMS regions. Each of the five New Hampshire Regional Councils was asked to make Trauma Center designations based on the Exclusive Trauma System Model. Under the exclusive model, trauma care resources were limited to a small number of designated facilities. These hospitals were promoted as the only ones that could care for trauma patients within a particular area. Exclusive Trauma System efforts were not successful across the state due to several factors including New Hampshire’s geography and weather, wide variations in population density, and the different trauma center capabilities of hospitals in the five regions. In 1992 and 1994 New Hampshire’s Bureau of EMS received two trauma care system planning grants from HRSA for the development and implementation of a statewide inclusive Trauma System. The concept of an inclusive Trauma System recognizes the need for all hospitals that treat and admit trauma patients to participate in the Trauma System, regardless of geographic location, population density, and/or severity of the patient’s injury. The planning process indicated that a successful Trauma System in New Hampshire must integrate all health care resources available in the state and avoid fragmenting trauma care. *Plan was finalized in 1995.In the early 1980s New Hampshire began to look at Trauma System development. Initial effort focused on creating a regional Trauma System that worked within the existing EMS regions. Each of the five New Hampshire Regional Councils was asked to make Trauma Center designations based on the Exclusive Trauma System Model. Under the exclusive model, trauma care resources were limited to a small number of designated facilities. These hospitals were promoted as the only ones that could care for trauma patients within a particular area. Exclusive Trauma System efforts were not successful across the state due to several factors including New Hampshire’s geography and weather, wide variations in population density, and the different trauma center capabilities of hospitals in the five regions. In 1992 and 1994 New Hampshire’s Bureau of EMS received two trauma care system planning grants from HRSA for the development and implementation of a statewide inclusive Trauma System. The concept of an inclusive Trauma System recognizes the need for all hospitals that treat and admit trauma patients to participate in the Trauma System, regardless of geographic location, population density, and/or severity of the patient’s injury. The planning process indicated that a successful Trauma System in New Hampshire must integrate all health care resources available in the state and avoid fragmenting trauma care. *Plan was finalized in 1995.

    22. Trauma System Development: NH 1995: Statewide Trauma Plan Finalized Senate Bill 122 Trauma Coordinator position created Stakeholders Group formed Trauma Medical Review Committee named as the Trauma Systems Oversight Committee Bureau of EMS named as the Lead Agency New Hampshire’s Statewide Adult and Pediatric Trauma Plan was finalized in 1995 and enacted into law by the Legislature via Senate Bill 122. A Trauma Coordinator’s position was created and a stakeholders group was formed. The Trauma Medical Review Committee was named as the Trauma Systems Oversight Committee and the New Hampshire Bureau of EMS was named as the Lead Agency. Full implementation of the Trauma System, including data collection, evaluation, and quality improvement, has not occurred. The Trauma System’s impact on the process of trauma care and patient outcomes has not been analyzed. Participants in the 2001 Trauma System stakeholders meeting cited New Hampshire’s lack of data collection, monitoring, and feedback as key weaknesses and called for opportunities to advance hospital participation, data collection, and quality improvement. Action plans are currently underway to accomplish these things. Two main goals are: 1) to enhance Trauma and EMS System evaluation resources and capabilities by creating a Trauma-EMS Information Systems Committee responsible for the development of an evaluation system action plan and 2) to enhance trauma patient care reporting capabilities to strengthen the State’s out-of-hospital database by hiring a half-time trauma documentation project coordinator and identifying key trauma data fields and monitor for reporting compliance. New Hampshire’s Statewide Adult and Pediatric Trauma Plan was finalized in 1995 and enacted into law by the Legislature via Senate Bill 122. A Trauma Coordinator’s position was created and a stakeholders group was formed. The Trauma Medical Review Committee was named as the Trauma Systems Oversight Committee and the New Hampshire Bureau of EMS was named as the Lead Agency. Full implementation of the Trauma System, including data collection, evaluation, and quality improvement, has not occurred. The Trauma System’s impact on the process of trauma care and patient outcomes has not been analyzed. Participants in the 2001 Trauma System stakeholders meeting cited New Hampshire’s lack of data collection, monitoring, and feedback as key weaknesses and called for opportunities to advance hospital participation, data collection, and quality improvement. Action plans are currently underway to accomplish these things. Two main goals are: 1) to enhance Trauma and EMS System evaluation resources and capabilities by creating a Trauma-EMS Information Systems Committee responsible for the development of an evaluation system action plan and 2) to enhance trauma patient care reporting capabilities to strengthen the State’s out-of-hospital database by hiring a half-time trauma documentation project coordinator and identifying key trauma data fields and monitor for reporting compliance.

    23. Trauma System Development: NH 1999: Trauma Triage, Communications, and Transport Decision Making Educational Program offered 2002: TEMSIS Grant 2004: Trauma Documentation and Triage Resource Guide In the fall of 1999, a Trauma Triage, Communications, and Transport Decision Making Educational Program was rolled out to prehospital instructors in New Hampshire. A tool kit for lead Emergency Medical Technician (EMT) Instructor-Coordinators (I/C) at all levels was prepared and distributed during a series of workshops throughout the state. Curricula, a power point presentation, and resource materials were provided to EMT I/Cs. From there, a statewide educational effort was underway with the goal of having all prehospital providers using the same set of Severity Indicators for identifying high risk trauma patients. Also addressed in this program was a standard format for radio communications and transport decision-making options. TEMSIS: Trauma EMS Information Systems. Goals: Develop information systems that are able to describe an entire EMS event; Adopt a uniform data set/definitions; Develop mechanisms to generate and transmit data that are valid, reliable, and accurate; Develop integrated information systems with other health care providers, public safety agencies, and community resources; Provide feedback to those who generate data. Grant funding from a statewide rural health initiative has helped continue to support this ongoing effort. This Trauma Documentation and Triage Resource Manual and train-the-trainer program represents a continuation of those efforts. In the fall of 1999, a Trauma Triage, Communications, and Transport Decision Making Educational Program was rolled out to prehospital instructors in New Hampshire. A tool kit for lead Emergency Medical Technician (EMT) Instructor-Coordinators (I/C) at all levels was prepared and distributed during a series of workshops throughout the state. Curricula, a power point presentation, and resource materials were provided to EMT I/Cs. From there, a statewide educational effort was underway with the goal of having all prehospital providers using the same set of Severity Indicators for identifying high risk trauma patients. Also addressed in this program was a standard format for radio communications and transport decision-making options. TEMSIS: Trauma EMS Information Systems. Goals: Develop information systems that are able to describe an entire EMS event; Adopt a uniform data set/definitions; Develop mechanisms to generate and transmit data that are valid, reliable, and accurate; Develop integrated information systems with other health care providers, public safety agencies, and community resources; Provide feedback to those who generate data. Grant funding from a statewide rural health initiative has helped continue to support this ongoing effort. This Trauma Documentation and Triage Resource Manual and train-the-trainer program represents a continuation of those efforts.

    24. NH Trauma System Components Prevention & Public Education Hospitals & EMS Providers Medical Direction: On-line & Standing Orders Triage & Transport Guidelines Rehabilitation Evaluation EXAMPLES/DATA: Prevention & Public Education: seatbelt & helmet use (although not mandatory in NH), Shattered Dreams type programs, Car Seat education/use Hospitals & EMS Providers: NH has >4,600 providers, 60% volunteer, primarily EMT-B level. >96,000 requests/year Medical Direction: On-line & Standing Orders Triage & Transport Guidelines: e.g. this program, triage card, state trauma plan Rehabilitation EvaluationEXAMPLES/DATA: Prevention & Public Education: seatbelt & helmet use (although not mandatory in NH), Shattered Dreams type programs, Car Seat education/use Hospitals & EMS Providers: NH has >4,600 providers, 60% volunteer, primarily EMT-B level. >96,000 requests/year Medical Direction: On-line & Standing Orders Triage & Transport Guidelines: e.g. this program, triage card, state trauma plan Rehabilitation Evaluation

    25. “Need to Know” Information Hospital Assessment Trauma Triage Guidelines Communication Guidelines Transport Guidelines WHAT are your local hospital’s capabilities? What status is your patient? What are the patient’s needs? Early and continued communication with Medical irection and the Trauma Center is a must. Transport decisions in cooperation with Medical Direction.WHAT are your local hospital’s capabilities? What status is your patient? What are the patient’s needs? Early and continued communication with Medical irection and the Trauma Center is a must. Transport decisions in cooperation with Medical Direction.

    26. Hospital Assessment Performance Levels Initial, Advanced, or Leadership Roles Area or Regional There are three Levels of Performance: Initial, Advanced, and Leadership. The Performance Levels are the same in both the Adult and Pediatric Trauma Systems. Today, the system has only clearly defined the Initial and Advanced levels: Initial Level: A staffed Emergency Department open twenty-four hours a day (*has NOT participated in a site visit) Advanced Level: (*has participated in a site visit) Hospitals complete the Self-Assessment Tool Hospitals voluntarily participate in the On-Site Review Process These hospitals are required to submit data requested to the Lead Agency, which is NH BEMS (& or thru? The Trauma Medical Review Committee) Once a hospital chooses to participate at the Advanced Level, they are asked to declare their role in the receiving and transporting of patients. The Roles defined in both the Adult and Pediatric plans are: Area: Area Hospitals receive trauma patients from their own catchment area and transfer out patients that exceed their clinical capabilities Regional: Regional Hospitals receive trauma patients from their own area as well as transfers from Area Hospitals. These Roles are the same in both the Adult and Pediatric Trauma SystemsThere are three Levels of Performance: Initial, Advanced, and Leadership. The Performance Levels are the same in both the Adult and Pediatric Trauma Systems. Today, the system has only clearly defined the Initial and Advanced levels: Initial Level: A staffed Emergency Department open twenty-four hours a day (*has NOT participated in a site visit) Advanced Level: (*has participated in a site visit) Hospitals complete the Self-Assessment Tool Hospitals voluntarily participate in the On-Site Review Process These hospitals are required to submit data requested to the Lead Agency, which is NH BEMS (& or thru? The Trauma Medical Review Committee) Once a hospital chooses to participate at the Advanced Level, they are asked to declare their role in the receiving and transporting of patients. The Roles defined in both the Adult and Pediatric plans are: Area: Area Hospitals receive trauma patients from their own catchment area and transfer out patients that exceed their clinical capabilities Regional: Regional Hospitals receive trauma patients from their own area as well as transfers from Area Hospitals. These Roles are the same in both the Adult and Pediatric Trauma Systems

    27. Hospital Assessment Capability Levels Adult & Pediatric; Level I, II, or III It is within the criteria for Clinical Capability Levels that our System requires hospitals to declare what patients they are fully capable of managing and what patients need to move on to another facility, either from the scene or as an interfacility transfer. It is here that an entire institution makes a commitment, versus the effort of a single provider or department: the entire system must be capable of caring for the types of patients identified. In New Hampshire there are Level I, II, and III Trauma Hospitals: Level III Trauma Hospitals: Provide initial care for trauma patients. At this level, hospitals provide prompt assessment, stabilization, resuscitation, and emergency surgery for trauma patients. They have a plan in place for the rapid identification and transfer of most moderate to all severely injured patients to a Hospital of higher Clinical Capability. Typically Level III Trauma Centers are community hospitals that do not have ready access to a definitive trauma care facility (Level II and I). They are required to have a General Surgeon available within 30 minutes. Level III Pediatric Trauma Hospitals transfer out all severe are moderately injured patients. Level II Trauma Hospitals: In New Hampshire provide initial definitive care for a majority of trauma patients from their area. The exception here would be a more complex multi-system trauma patient. These patients require advanced and extended surgical and critical care. As an institution they have decided what patients rise above the threshold for admission, and have a plan in place for expedient transfer. For the patients that meet the admission criteria of a Level II, a plan for a multi-disciplinary team response to the Emergency Department must be in place, including a General Surgeon and Neurosurgeon within thirty minutes. As a Level II Pediatric Trauma Hospital, patients with an ISS of <9 and/or on a ventilator are transferred out to a Level I pediatric hospital. The majority of moderately injured children are transferred as well. In New Hampshire today, many Level II Trauma Centers are experiencing difficulty in meeting the requirements for Neurosurgery coverage 24/7. This is not a unique experience to New Hampshire. Level I Trauma Hospital: Serves as a resource for their immediate area as well as the region they serve. These hospitals provide definitive, tertiary care for all levels of trauma patients and are central to the functioning of the Trauma System they work within. A Level I Trauma Hospital serves as a leader in patient care, education, and research for trauma patients. They provide comprehensive trauma patient services: prevention, emergency care, surgical services, inpatient critical care, and rehabilitation. Typically, these facilities host residency training programs in Emergency Medicine and/or Surgery. Within the Pediatric Trauma System, a Level I is prepared to manage all types of injured children. **For specific requirements for each Level, refer to the State Trauma Plan*It is within the criteria for Clinical Capability Levels that our System requires hospitals to declare what patients they are fully capable of managing and what patients need to move on to another facility, either from the scene or as an interfacility transfer. It is here that an entire institution makes a commitment, versus the effort of a single provider or department: the entire system must be capable of caring for the types of patients identified. In New Hampshire there are Level I, II, and III Trauma Hospitals: Level III Trauma Hospitals: Provide initial care for trauma patients. At this level, hospitals provide prompt assessment, stabilization, resuscitation, and emergency surgery for trauma patients. They have a plan in place for the rapid identification and transfer of most moderate to all severely injured patients to a Hospital of higher Clinical Capability. Typically Level III Trauma Centers are community hospitals that do not have ready access to a definitive trauma care facility (Level II and I). They are required to have a General Surgeon available within 30 minutes. Level III Pediatric Trauma Hospitals transfer out all severe are moderately injured patients. Level II Trauma Hospitals: In New Hampshire provide initial definitive care for a majority of trauma patients from their area. The exception here would be a more complex multi-system trauma patient. These patients require advanced and extended surgical and critical care. As an institution they have decided what patients rise above the threshold for admission, and have a plan in place for expedient transfer. For the patients that meet the admission criteria of a Level II, a plan for a multi-disciplinary team response to the Emergency Department must be in place, including a General Surgeon and Neurosurgeon within thirty minutes. As a Level II Pediatric Trauma Hospital, patients with an ISS of <9 and/or on a ventilator are transferred out to a Level I pediatric hospital. The majority of moderately injured children are transferred as well. In New Hampshire today, many Level II Trauma Centers are experiencing difficulty in meeting the requirements for Neurosurgery coverage 24/7. This is not a unique experience to New Hampshire. Level I Trauma Hospital: Serves as a resource for their immediate area as well as the region they serve. These hospitals provide definitive, tertiary care for all levels of trauma patients and are central to the functioning of the Trauma System they work within. A Level I Trauma Hospital serves as a leader in patient care, education, and research for trauma patients. They provide comprehensive trauma patient services: prevention, emergency care, surgical services, inpatient critical care, and rehabilitation. Typically, these facilities host residency training programs in Emergency Medicine and/or Surgery. Within the Pediatric Trauma System, a Level I is prepared to manage all types of injured children. **For specific requirements for each Level, refer to the State Trauma Plan*

    28. Hospital Assessment: Process Hospital Staff Self-Assessment Site Visit by Members of TMRC Confirmation / Consultative Assistance *For more information, contact Clay Odell Site Visit: Team (TMRC) consists of adult and pediatric surgeons with trauma experience, ED physician, Ed Nurse, trauma nurse coordinator, NH Trauma Coordinator, and NH EMS-C Coordinator. Process: hospital tour; hospital staff reports; medical chart review; review of minutes, committee records, and trauma data. Role of Site Visit Team: Confirmation of hospital self assessment; Assistance and consultation for the improvement of trauma care*For more information, contact Clay Odell Site Visit: Team (TMRC) consists of adult and pediatric surgeons with trauma experience, ED physician, Ed Nurse, trauma nurse coordinator, NH Trauma Coordinator, and NH EMS-C Coordinator. Process: hospital tour; hospital staff reports; medical chart review; review of minutes, committee records, and trauma data. Role of Site Visit Team: Confirmation of hospital self assessment; Assistance and consultation for the improvement of trauma care

    29. 12 (of 26) hospitals are currently assigned: 1 Level I; 4 Level IIs, 7 Level IIIs 12 (of 26) hospitals are currently assigned: 1 Level I; 4 Level IIs, 7 Level IIIs

    30. BREAKBREAK

    31. What is Trauma Triage? A method of matching the needs of the trauma patient to the resources of the hospital. Trauma patients are assessed and transported to the most appropriate hospital for that patient’s injuries. The goal of prehospital care of trauma patients is to minimize injury through safe and rapid transport of the patient to the facility most appropriately equipped and staffed to treat the patient’s injuries. This is where trauma triage plays a crucial role. What exactly is trauma triage? It is a process by which trauma patients are assessed and transported to the most appropriate trauma facility for that patient’s injuries. This goes back to the Trauma System goal of getting the right patient to the right hospital in the right time. The goal of prehospital care of trauma patients is to minimize injury through safe and rapid transport of the patient to the facility most appropriately equipped and staffed to treat the patient’s injuries. This is where trauma triage plays a crucial role. What exactly is trauma triage? It is a process by which trauma patients are assessed and transported to the most appropriate trauma facility for that patient’s injuries. This goes back to the Trauma System goal of getting the right patient to the right hospital in the right time.

    32. Trauma Triage Appropriate: Right Patient to the Right Hospital at the Right Time OVER Triage: Minimally injured pts are transported to Trauma Centers Result: Overburdens the system, no ill effect on pt care UNDER Triage: Severely injured pts are transported to Non-Trauma Centers Result: Hospitals may not be equipped to treat the pt and pt care may suffer Inaccuracy in trauma triage results in either over-triage (minimally inured patients are transferred to trauma centers) or under-triage (severely inured patients are taken to non-trauma centers). In under-triage, critically injured patients are taken to hospitals that are not fully staffed or equipped to meet all of the patient’s life- and limb-saving needs. In over-triage, minimally injured patients are taken to trauma centers that may already be overburdened with critical trauma patients. When triaging patients, a priority is generally given to reducing under-triage because under-triage may result in preventable disability and death from delays to definitive care. Although over-triage causes minimal to no adverse effects on the patient, it does result in excessive cost and burden to the trauma center. According to the American College of Surgeons Committee on Trauma (ACS COT), in most systems an under-triage rate of 5-10% is considered unavoidable and is associated with an over-triage rate 30-50%. The trauma system’s performance improvement plan is designed to evaluate the triage criteria to afford the best balance between access to quality care for severely injured patients without overtaxing the receiving trauma facility with minimally injured patients or inappropriately transporting minimally injured patients long distances. Inaccuracy in trauma triage results in either over-triage (minimally inured patients are transferred to trauma centers) or under-triage (severely inured patients are taken to non-trauma centers). In under-triage, critically injured patients are taken to hospitals that are not fully staffed or equipped to meet all of the patient’s life- and limb-saving needs. In over-triage, minimally injured patients are taken to trauma centers that may already be overburdened with critical trauma patients. When triaging patients, a priority is generally given to reducing under-triage because under-triage may result in preventable disability and death from delays to definitive care. Although over-triage causes minimal to no adverse effects on the patient, it does result in excessive cost and burden to the trauma center. According to the American College of Surgeons Committee on Trauma (ACS COT), in most systems an under-triage rate of 5-10% is considered unavoidable and is associated with an over-triage rate 30-50%. The trauma system’s performance improvement plan is designed to evaluate the triage criteria to afford the best balance between access to quality care for severely injured patients without overtaxing the receiving trauma facility with minimally injured patients or inappropriately transporting minimally injured patients long distances.

    33. How do we perform Trauma Triage? Triage & Transport Pathways Card Standardized Injury Severity Indicators GCS RTS Provider experience/judgment OVERVIEW only – more detail on the next slide Triage Card: provided in your handout/folder. More are available through the NHBEMS and the EMS-C Program RTS & GCS: We realize these scores might not be calculated by every provider in the field, BUT they are important tools to identify major trauma patients (those who need a Trauma Center) Provider Experience & Judgment: That feeling in your gut that tells you “sick” v. “not sick”. ALSO – know your local resources.OVERVIEW only – more detail on the next slide Triage Card: provided in your handout/folder. More are available through the NHBEMS and the EMS-C Program RTS & GCS: We realize these scores might not be calculated by every provider in the field, BUT they are important tools to identify major trauma patients (those who need a Trauma Center) Provider Experience & Judgment: That feeling in your gut that tells you “sick” v. “not sick”. ALSO – know your local resources.

    34. Steps to Increase Likelihood of Appropriate Trauma Triage Know the “Trauma Triage and Transport Pathways” Reference card is available through NH Department of Safety & EMS-C program Be familiar with severity indicators (GCS & RTS) Know your local resources On Scene: Mutual Aid, ALS Intercept, Air Transport Hospital: Local Hospital capabilities & distance to Regional Trauma Center In order to perform Trauma Triage accurately, providers must be familiar with severity indicators, or scoring systems and scales. These are outlined below/later. In addition, providers must discuss in a proactive manner their local resources including their own abilities, ALS intercept, air medical resources, local hospital capabilities, and regional trauma center distance and capabilities. Algorithms on which types of patients to transport where must be developed in cooperation with local medical control. Every person in New Hampshire who has sustained a significant or critical injury should be transported to a hospital which has the capability of providing definitive trauma care for that patient’s injuries. Every person who has sustained a minor or moderate injury should be transported to the nearest hospital. Potential exceptions to this may be applied if prehospital providers are: 1). unable to maintain an adequate airway or 2). if the expected transport time to a trauma center exceeds 30 minutes. In the first case, and possibly in the second case, it is appropriate to transport the patient to the nearest hospital. In order to perform Trauma Triage accurately, providers must be familiar with severity indicators, or scoring systems and scales. These are outlined below/later. In addition, providers must discuss in a proactive manner their local resources including their own abilities, ALS intercept, air medical resources, local hospital capabilities, and regional trauma center distance and capabilities. Algorithms on which types of patients to transport where must be developed in cooperation with local medical control. Every person in New Hampshire who has sustained a significant or critical injury should be transported to a hospital which has the capability of providing definitive trauma care for that patient’s injuries. Every person who has sustained a minor or moderate injury should be transported to the nearest hospital. Potential exceptions to this may be applied if prehospital providers are: 1). unable to maintain an adequate airway or 2). if the expected transport time to a trauma center exceeds 30 minutes. In the first case, and possibly in the second case, it is appropriate to transport the patient to the nearest hospital.

    35. Prehospital Trauma Triage involves assessment and evaluation that includes physiological assessment, trauma scoring, anatomical injury assessment, mechanism of injury, and age related criteria. The physiological assessment results in the calculation of a Revised Trauma Score (RTS) which is a scoring system that utilizes the Glascow Coma Scale (GCS) score and the patient’s respiratory rate (RR) and blood pressure (BP). Each physiological finding is assigned a numerical score. The lower the score, the more severe the injury. The anatomy of injury assessment describes the visible evidence of the injury, such as amputation above the wrist. The mechanism of injury assessment relates to a high energy event, such as an MVC involving death of a co-occupant. Another important consideration is the “gut feeling” of the experienced prehospital provider or the existence of co-morbid factors, such as extremes of age. **Review Patient Status Categories (color coded)Prehospital Trauma Triage involves assessment and evaluation that includes physiological assessment, trauma scoring, anatomical injury assessment, mechanism of injury, and age related criteria. The physiological assessment results in the calculation of a Revised Trauma Score (RTS) which is a scoring system that utilizes the Glascow Coma Scale (GCS) score and the patient’s respiratory rate (RR) and blood pressure (BP). Each physiological finding is assigned a numerical score. The lower the score, the more severe the injury. The anatomy of injury assessment describes the visible evidence of the injury, such as amputation above the wrist. The mechanism of injury assessment relates to a high energy event, such as an MVC involving death of a co-occupant. Another important consideration is the “gut feeling” of the experienced prehospital provider or the existence of co-morbid factors, such as extremes of age. **Review Patient Status Categories (color coded)

    36. The physiological assessment results in the calculation of a Revised Trauma Score (RTS) which is a scoring system that utilizes the: * Glascow Coma Scale (GCS) score and * the patient’s respiratory rate (RR) and * SYSTOLIC blood pressure (BP). Each physiological finding is assigned a numerical score. The lower the score, the more severe the injury. *The RTS may not be calculated on scene at the time of the call. It should utilize the FIRST set of vitals (or the lowest GCS and SBP) The RTS can easily be calculated using the PCR – circle the appropriate number for GCS and vitals – add up the total. (more examples to follow later in this presentation).The physiological assessment results in the calculation of a Revised Trauma Score (RTS) which is a scoring system that utilizes the: * Glascow Coma Scale (GCS) score and * the patient’s respiratory rate (RR) and * SYSTOLIC blood pressure (BP). Each physiological finding is assigned a numerical score. The lower the score, the more severe the injury. *The RTS may not be calculated on scene at the time of the call. It should utilize the FIRST set of vitals (or the lowest GCS and SBP) The RTS can easily be calculated using the PCR – circle the appropriate number for GCS and vitals – add up the total. (more examples to follow later in this presentation).

    37. **emphasize Air transport* per Clay Odell The anatomy of injury assessment describes the visible evidence of the injury, such as amputation above the wrist. **emphasize Air transport* per Clay Odell The anatomy of injury assessment describes the visible evidence of the injury, such as amputation above the wrist.

    38. The mechanism of injury assessment relates to a high energy event, such as an MVC involving death of a co-occupant. MOI: NOT the most accurate predictor (often results in over triage) Another important consideration is the “gut feeling” of the experienced prehospital provider or the existence of co-morbid factors, such as extremes of age. Co-Morbid factors place patients at greater risk of a poor outcome. The mechanism of injury assessment relates to a high energy event, such as an MVC involving death of a co-occupant. MOI: NOT the most accurate predictor (often results in over triage) Another important consideration is the “gut feeling” of the experienced prehospital provider or the existence of co-morbid factors, such as extremes of age. Co-Morbid factors place patients at greater risk of a poor outcome.

    39. TRANSPORT DECISION: Made in cooperation with Medical Control Factors: Driving time (distance, road conditions, traffic, weather, urban v. rural/wilderness areas) Extrication (or carry patient out to the nearest road) time ALS estimated time of arrival / availability Air transport estimated time of arrival (distance, weather, landing zone site) Patient’s medical needs v. hospital’s clinical capabilities Ongoing CPR Multiple patients Rule of Thumb for Status I and II patients: If extrication plus ground transportation time to local hospital is less than air transport arrival to scene, transport patient by ambulance to local hospital for initial care. Request for air transport should not be delayed due to decision to ground transport to local hospital. Helicopter can be diverted to local hospital’s landing zone for transport to hospital with higher trauma care capabilities. **It is NOT an EMTALA violation to rendezvous with a helicopter on a hospital’s helipad. If the hospital staff come out to the EMS unit or the patient is taken inside, then the proper transfer/EMTALA procedure must be complied with. Do not hesitate to request air transport as it can be cancelled if further assessment indicates the patient does not need air transport. There is no charge for this.TRANSPORT DECISION: Made in cooperation with Medical Control Factors: Driving time (distance, road conditions, traffic, weather, urban v. rural/wilderness areas) Extrication (or carry patient out to the nearest road) time ALS estimated time of arrival / availability Air transport estimated time of arrival (distance, weather, landing zone site) Patient’s medical needs v. hospital’s clinical capabilities Ongoing CPR Multiple patients Rule of Thumb for Status I and II patients: If extrication plus ground transportation time to local hospital is less than air transport arrival to scene, transport patient by ambulance to local hospital for initial care. Request for air transport should not be delayed due to decision to ground transport to local hospital. Helicopter can be diverted to local hospital’s landing zone for transport to hospital with higher trauma care capabilities. **It is NOT an EMTALA violation to rendezvous with a helicopter on a hospital’s helipad. If the hospital staff come out to the EMS unit or the patient is taken inside, then the proper transfer/EMTALA procedure must be complied with. Do not hesitate to request air transport as it can be cancelled if further assessment indicates the patient does not need air transport. There is no charge for this.

    40. ** More detail on the GCS and RTS in the section on documentation NEXT several slides: Break down each Scale & Scoring System…** More detail on the GCS and RTS in the section on documentation NEXT several slides: Break down each Scale & Scoring System…

    41. ** More detail on the GCS and RTS in the section on documentation (how to calculate, examples…) There are studies (including some in you TtT packet) that support GCS Motor of <6 as an accurate predictor of a Major Trauma Patient There is one study in your TtT packet that supports RR>25 as an accurate predictor of a Major Trauma Patient** More detail on the GCS and RTS in the section on documentation (how to calculate, examples…) There are studies (including some in you TtT packet) that support GCS Motor of <6 as an accurate predictor of a Major Trauma Patient There is one study in your TtT packet that supports RR>25 as an accurate predictor of a Major Trauma Patient

    42. ** More detail on the GCS and RTS in the section on documentation “AVPU” is a very quick/easy way to assess and report mental status. It can be used on adults as well as pediatric patients.** More detail on the GCS and RTS in the section on documentation “AVPU” is a very quick/easy way to assess and report mental status. It can be used on adults as well as pediatric patients.

    43. ** More detail on the GCS and RTS in the section on documentation Coded points <11 = goes to a Trauma Center CODED VALUE x factor = add all together and you get the “coded RTS” (next slide shows formula and calculator website)** More detail on the GCS and RTS in the section on documentation Coded points <11 = goes to a Trauma Center CODED VALUE x factor = add all together and you get the “coded RTS” (next slide shows formula and calculator website)

    44. TRUE “coded RTS” : you might see this formula used in journal articles (and on the Trauma.org website) Uses the FIRST set of values/vital signs obtained (*This is one reason why it is essential that this info get to the Trauma Center & on the Patient’s Trauma Chart!) More complicated to calculate, which limits its usefulness in the field. Main advantage of the coded RTS is that the weighting of the individual components emphasizes the significant impact of traumatic brain injury on outcome. EXAMPLE: SBP 90 (coded value 4) [4 x 0.7326] = 2.9304 RR 10 (coded value 4) [4 x 0.2908] = 1.1632 GCS 13 (coded value 4) [4 x 0.9368] = 3.7472 RTS = 7.841 **Emphasize: This is complicated & will NOT be calculated in the field, but it is good information to know.TRUE “coded RTS” : you might see this formula used in journal articles (and on the Trauma.org website) Uses the FIRST set of values/vital signs obtained (*This is one reason why it is essential that this info get to the Trauma Center & on the Patient’s Trauma Chart!) More complicated to calculate, which limits its usefulness in the field. Main advantage of the coded RTS is that the weighting of the individual components emphasizes the significant impact of traumatic brain injury on outcome. EXAMPLE: SBP 90 (coded value 4) [4 x 0.7326] = 2.9304 RR 10 (coded value 4) [4 x 0.2908] = 1.1632 GCS 13 (coded value 4) [4 x 0.9368] = 3.7472 RTS = 7.841 **Emphasize: This is complicated & will NOT be calculated in the field, but it is good information to know.

    45. RTS & % Survival The coded RTS correlates well to the probability of survival (Ps) EXAMPLE: RTS of 7.841 = Ps of 98.8% RTS of 5 = Ps of 80.7%The coded RTS correlates well to the probability of survival (Ps) EXAMPLE: RTS of 7.841 = Ps of 98.8% RTS of 5 = Ps of 80.7%

    46. ** More detail on the GCS and RTS in the section on documentation** More detail on the GCS and RTS in the section on documentation

    47. Early and frequent communication is vital to good system-wide trauma care because prehospital communication to Medical Control will help determine trauma team activation and transport decision. The content of the initial scene communication must be pertinent. Relay the following information: General call information Service name Patient’s age and sex ETA Status determination Patient information Level of consciousness (AVPU, GCS, or description of patient’s behavior) Airway status Respiratory rate and rhythm Breath sounds Skin color, temperature, and condition Blood pressure Pupils Revised Trauma Score (RTS) Incident facts Location Number of patients Mechanism of injury Mutual aid Estimated extrication time During transport Re-identify unit Update patient status level Describe major injuries Changes in condition Update vital signs Treatment (and patient response) SAMPLE history An acronym that many providers find useful in remembering what information to give and in what order is “MIVT”: M: Mechanism I: Injuries V: Vitals T: Treatment (and response) Early and frequent communication is vital to good system-wide trauma care because prehospital communication to Medical Control will help determine trauma team activation and transport decision. The content of the initial scene communication must be pertinent. Relay the following information: General call information Service name Patient’s age and sex ETA Status determination Patient information Level of consciousness (AVPU, GCS, or description of patient’s behavior) Airway status Respiratory rate and rhythm Breath sounds Skin color, temperature, and condition Blood pressure Pupils Revised Trauma Score (RTS) Incident facts Location Number of patients Mechanism of injury Mutual aid Estimated extrication time During transport Re-identify unit Update patient status level Describe major injuries Changes in condition Update vital signs Treatment (and patient response) SAMPLE history An acronym that many providers find useful in remembering what information to give and in what order is “MIVT”: M: Mechanism I: Injuries V: Vitals T: Treatment (and response)

    48. Trauma Triage Steps: To Recap Use Pathway Card/Info to determine Pt Status Trauma Triage Communication Contact Medical Control Relay enough info to aid in decision making process Refer to “Trauma Communications” on Card Minimum information to relay: “MIVT” Transport Decision ? Transport Define “MIVT” – mechanism, injuries, vitals, treatment The decision on where to transport and by what type of vehicle/crew composition is made in cooperation with medical control. Factors to consider include: Driving time: distances, road conditions, traffic, weather, urban v. rural/wilderness Extrication time (or time to carry patient to the nearest road) Air transport estimated time of arrival (distance, weather, landing zone site) Patient’s medical needs v. hospital’s clinical capabilities Ongoing CPR Need for critical interventions Multiple patients Rules of thumb for Status I and II patients: If extrication time plus ground transportation time to local hospital is less than air transport arrival time to scene, transport by ambulance to local hospital for initial care. Request for air transport should not be delayed due to decision to ground transport to local hospital. The helicopter can be diverted to the local hospital’s landing zone for transport to a hospital with higher trauma care capabilities. Do not hesitate to request air transport as it can be cancelled if further assessment indicates the patient does not need air transport. Define “MIVT” – mechanism, injuries, vitals, treatment The decision on where to transport and by what type of vehicle/crew composition is made in cooperation with medical control. Factors to consider include: Driving time: distances, road conditions, traffic, weather, urban v. rural/wilderness Extrication time (or time to carry patient to the nearest road) Air transport estimated time of arrival (distance, weather, landing zone site) Patient’s medical needs v. hospital’s clinical capabilities Ongoing CPR Need for critical interventions Multiple patients Rules of thumb for Status I and II patients: If extrication time plus ground transportation time to local hospital is less than air transport arrival time to scene, transport by ambulance to local hospital for initial care. Request for air transport should not be delayed due to decision to ground transport to local hospital. The helicopter can be diverted to the local hospital’s landing zone for transport to a hospital with higher trauma care capabilities. Do not hesitate to request air transport as it can be cancelled if further assessment indicates the patient does not need air transport.

    49. BREAK There are more comprehensive Trauma Triage scenarios available in the Resource Guide… There is one example provided here BREAK There are more comprehensive Trauma Triage scenarios available in the Resource Guide… There is one example provided here

    50. Trauma Triage Scenario 1

    51. Scenario 1

    52. Scene Info Motorcycle v. Pickup Truck Truck traveling 40 mph, ? Cycle speed 30 y/o male thrown 20 feet Truck has damage Rider’s helmet has few, minor scratches THE TWO QUESTIONS: mainly for discussion at this point. -Major MOI -Assessment info (use Triage Card as a reference) On a Sunday afternoon, the ambulance and local FAST squad are called to a rural road for the report of a motorcycle crash. According to the Dispatcher, one male adult has been injured after his motorcycle was struck by a pick up truck. Witnesses state the patient was separated from his motorcycle on impact and thrown approximately twenty feet. The driver of the pick up truck was stated to be traveling approximately 40 mph; it is unknown how fast the motorcycle was traveling. FAST squad members on scene report to you that this is a male patient in his 30s that is responsive to verbal stimuli. Upon arrival on the scene you note a large crowd of bystanders. There are two hospitals in your service area, both Regional Level II Trauma Hospitals. One is 10 minutes from the scene and the other is 20 minutes away. The hospital that is 20 minutes away is your medical resource facility. Flight time to the scene is 20 minutes. THE TWO QUESTIONS: mainly for discussion at this point. -Major MOI -Assessment info (use Triage Card as a reference) On a Sunday afternoon, the ambulance and local FAST squad are called to a rural road for the report of a motorcycle crash. According to the Dispatcher, one male adult has been injured after his motorcycle was struck by a pick up truck. Witnesses state the patient was separated from his motorcycle on impact and thrown approximately twenty feet. The driver of the pick up truck was stated to be traveling approximately 40 mph; it is unknown how fast the motorcycle was traveling. FAST squad members on scene report to you that this is a male patient in his 30s that is responsive to verbal stimuli. Upon arrival on the scene you note a large crowd of bystanders. There are two hospitals in your service area, both Regional Level II Trauma Hospitals. One is 10 minutes from the scene and the other is 20 minutes away. The hospital that is 20 minutes away is your medical resource facility. Flight time to the scene is 20 minutes.

    53. Initial Assessment Opens eyes to loud verbal stimuli Localizes painful stimuli Confused verbal response to questions Airway is open and clear RR=32, ? chest expansion, R. wall bruising Strong radial pulses, no major bleeding Skin pale, moist, cool GCS: E3, M5, V4=12 RTS: no, need SBP (+radial pulse =>80, but RTS goes by BP>89, 76-89, etc). Can estimate: GCS3, RR 3, BP 3-4 = 9-10 Initial Observations and Scene Size Up: 30 y/o male supine, in care of FAST squad The motorcycle and the patient were separated by at least 20 feet Damage to the front end of the pick up truck is moderate Pt was wearing a helmet, which has sustained little to no damage and has been removed by the FAST squad The scene is safe You are part of a two-person crew, one EMT-I and one EMT-B The pt is bleeding from wounds to his left lower leg and right arm, with deformity to the lower leg noted Pt also has some abrasions on his right arm and right side of his body Information from Initial Assessment: General Impression: 30 y/o male LOC: Responsive to loud stimuli, does not respond to questions or commands appropriately, does not follow commands, localizes pain Airway: open and clear C-Spine: A FAST squad member is immobilizing Breathing: Pt is breathing approximately 32 times per minute. Chest expansion is unequal with crepitus and diminished breath sounds noted on the right Circulation: A carotid pulse of 100 is noted and strong radial pulses are present. The pt’s skin is pale, moist, and cool. There is no major bleeding noted. Status determination: Based on the initial assessment of this patient (LOC, GCS 12, RTS 10, MOI+) = Status II GCS: E3, M5, V4=12 RTS: no, need SBP (+radial pulse =>80, but RTS goes by BP>89, 76-89, etc). Can estimate: GCS3, RR 3, BP 3-4 = 9-10 Initial Observations and Scene Size Up: 30 y/o male supine, in care of FAST squad The motorcycle and the patient were separated by at least 20 feet Damage to the front end of the pick up truck is moderate Pt was wearing a helmet, which has sustained little to no damage and has been removed by the FAST squad The scene is safe You are part of a two-person crew, one EMT-I and one EMT-B The pt is bleeding from wounds to his left lower leg and right arm, with deformity to the lower leg noted Pt also has some abrasions on his right arm and right side of his body Information from Initial Assessment: General Impression: 30 y/o male LOC: Responsive to loud stimuli, does not respond to questions or commands appropriately, does not follow commands, localizes pain Airway: open and clear C-Spine: A FAST squad member is immobilizing Breathing: Pt is breathing approximately 32 times per minute. Chest expansion is unequal with crepitus and diminished breath sounds noted on the right Circulation: A carotid pulse of 100 is noted and strong radial pulses are present. The pt’s skin is pale, moist, and cool. There is no major bleeding noted. Status determination: Based on the initial assessment of this patient (LOC, GCS 12, RTS 10, MOI+) = Status II

    54. Focused H&P No obvious head injury, PERRLA No JVD or tracheal tugging, C-spine non-tender ? Chest expansion, crepitus, ? lung sounds R. Abdomen soft, pelvis stable Open L. femur fracture Abrasions and small laceration on R. arm Pulse = 100, BP 110/68, RR = 32 Medic alert tag for Coumadin use Focused History and Physical Exam – Expose as Necessary Head: Clear, no obvious injuries noted, pupils PERRLA Neck: No JVD or tracheal deviation noted, no c-spine deformities noted Chest: Abrasions noted to right side, chest expansion is unequal with crepitus and diminished breath sounds noted on the right Abdomen: Guarding noted in all four quadrants, no bruising noted Pelvis: Stable Lower extremities: Left lower leg has obvious deformity and an open would with bone exposed, good circulation and sensation noted Upper extremities: Small laceration to right lower arm, entire right arm covered by large abrasion Back: No injuries noted SAMPLE History: Patient has a medic alert tag on for coumadin use Vitals: Pulse 100; BP 110/68, RR 32 Focused History and Physical Exam – Expose as Necessary Head: Clear, no obvious injuries noted, pupils PERRLA Neck: No JVD or tracheal deviation noted, no c-spine deformities noted Chest: Abrasions noted to right side, chest expansion is unequal with crepitus and diminished breath sounds noted on the right Abdomen: Guarding noted in all four quadrants, no bruising noted Pelvis: Stable Lower extremities: Left lower leg has obvious deformity and an open would with bone exposed, good circulation and sensation noted Upper extremities: Small laceration to right lower arm, entire right arm covered by large abrasion Back: No injuries noted SAMPLE History: Patient has a medic alert tag on for coumadin use Vitals: Pulse 100; BP 110/68, RR 32

    55. Trauma Communications What pertinent information will you communicate to medical control? Discussion of Findings and Trauma Triage and Transport Decisions: Based on the results of your initial assessment, what is this patient’s Status Determination? Using the Trauma Triage and Transport Decision criteria, what transport decision would you expect Medical Control to make? Why? Using the information from both your Initial Assessment and Focused History and Physical Exam, what information would you provide to the hospital on your initial trauma communication and why? Based on the results of your Initial Assessment, what would you calculate this patient’s GCS to be? Using the Trauma Triage and Transport Decision criteria, how would you transport this patient, by ground or by air? Why? What about the patient’s medical history/SAMPLE – is that information pertinent? Trauma Communications: “MIVT” Mechanism Injuries Vitals Treatment (and response) Discussion of Findings and Trauma Triage and Transport Decisions: Based on the results of your initial assessment, what is this patient’s Status Determination? Using the Trauma Triage and Transport Decision criteria, what transport decision would you expect Medical Control to make? Why? Using the information from both your Initial Assessment and Focused History and Physical Exam, what information would you provide to the hospital on your initial trauma communication and why? Based on the results of your Initial Assessment, what would you calculate this patient’s GCS to be? Using the Trauma Triage and Transport Decision criteria, how would you transport this patient, by ground or by air? Why? What about the patient’s medical history/SAMPLE – is that information pertinent? Trauma Communications: “MIVT” Mechanism Injuries Vitals Treatment (and response)

    56. Transport Decision Injury Severity Hospital capability, location, driving time Area Level III Trauma Hospital is 10 minutes Regional Level I Hospital is 20 minutes ALS intercept is unavailable Helicopter is available and ETA to scene is 20 minutes Acceptable Actions: Decision to assign this patient a Status II Determination Decision to provide a trauma communication to the hospital which includes your Status Determination, Incident Facts, and a description of patient information Decision to provide this patient with a rapid assessment, care, and transportation Decision in coordination with Medical Control to transport this patient to a Regional Level II Trauma Hospital after providing them with the following information to assist in making this decision: calculation of Status II; calculation of GCS 12, RTS 10, chest wall injury, RR >29, MOI + Decision not to request air transport via Medical Control due to travel times by ground to a Regional Level II Trauma Hospital Key Points: Review the importance of pre-planning your service area resources, advanced life support, and air medical transport Review the importance of recognizing early which patients need to go to what Level Trauma Hospital and how to communicate to Medical Control Review the significance of using Status Determinations and early trauma communication with the hospital Review Trauma Triage criteria that providers should utilize when making transport decisions, including air medical transport Acceptable Actions: Decision to assign this patient a Status II Determination Decision to provide a trauma communication to the hospital which includes your Status Determination, Incident Facts, and a description of patient information Decision to provide this patient with a rapid assessment, care, and transportation Decision in coordination with Medical Control to transport this patient to a Regional Level II Trauma Hospital after providing them with the following information to assist in making this decision: calculation of Status II; calculation of GCS 12, RTS 10, chest wall injury, RR >29, MOI + Decision not to request air transport via Medical Control due to travel times by ground to a Regional Level II Trauma Hospital Key Points: Review the importance of pre-planning your service area resources, advanced life support, and air medical transport Review the importance of recognizing early which patients need to go to what Level Trauma Hospital and how to communicate to Medical Control Review the significance of using Status Determinations and early trauma communication with the hospital Review Trauma Triage criteria that providers should utilize when making transport decisions, including air medical transport

    58. BREAKBREAK

    60. Uses for Documentation Medical continuity of care Administrative QI Assess needs (community & agency) Billing & Reimbursement Research Legal Medical continuity of care: Information from the PCR may be useful for hospital health care providers Trending level of consciousness and/or vital signs Description or photograph of the MVC scene Description of the circumstances leading to the illness or injury Care rendered, and the patient’s response, prior to arrival at the hospital Administrative: Information for quality improvement and system management Agency-specific System-wide Assessment of community needs based on call volume and type Billing and reimbursement issues Research: Data collection and analysis Outcome data Legal: The PCR becomes a part of the patient’s permanent medical record Attorneys may refer to the PCR when preparing court actions The PCR may be your sole source of information about the case if you are called for a deposition or to testify The PCR may serve as evidence during a criminal case As a good rule of thumb, always write your PCR as if you know it will someday be used in a court proceeding – utilize the guidelines described in this document Medical continuity of care: Information from the PCR may be useful for hospital health care providers Trending level of consciousness and/or vital signs Description or photograph of the MVC scene Description of the circumstances leading to the illness or injury Care rendered, and the patient’s response, prior to arrival at the hospital Administrative: Information for quality improvement and system management Agency-specific System-wide Assessment of community needs based on call volume and type Billing and reimbursement issues Research: Data collection and analysis Outcome data Legal: The PCR becomes a part of the patient’s permanent medical record Attorneys may refer to the PCR when preparing court actions The PCR may be your sole source of information about the case if you are called for a deposition or to testify The PCR may serve as evidence during a criminal case As a good rule of thumb, always write your PCR as if you know it will someday be used in a court proceeding – utilize the guidelines described in this document

    61. General PCR Guidelines Complete a PCR for every call and every pt This includes when care or transport was: Requested Rendered Refused Cancelled If multiple agencies with different levels of care respond to the same patient (for example, BLS providers, who then call for ALS intercept, who then call for a helicopter) – each agency should complete a PCR documenting the care they provided to the patient. If multiple agencies respond on 1 patient, the PCRs will be linked (using Probabalistic Linkage – linked by at least 2 data points to ensure they are the same person…)If multiple agencies with different levels of care respond to the same patient (for example, BLS providers, who then call for ALS intercept, who then call for a helicopter) – each agency should complete a PCR documenting the care they provided to the patient. If multiple agencies respond on 1 patient, the PCRs will be linked (using Probabalistic Linkage – linked by at least 2 data points to ensure they are the same person…)

    62. General PCR Guidelines A written PCR is: Complete Accurate Legible Professional Complete: The PCR should be precise and comprehensive. Include all relevant information that might be pertinent now or at a later date. Exclude all superfluous information. You should complete both the check box and the narrative portion of the PCR. The narrative is the core of the PCR. INCLUDE pertinent POSITIVES and NEGATIVES… Accurate: Correct spelling and grammar, as well as use of only approved abbreviations and acronyms are essential. Misspelled words may lose their meaning, or worse, be used in court as “proof” if bad care. Non-approved abbreviations may be misinterpreted. Several acronyms have more than one meaning – it is best to utilize only acronyms and/or abbreviations that have been approved by the State or the EMS agency. Legible: Penmanship must be neat, as several people may rely on the information contained in your report. Also, you might be called upon to review your PCR for legal proceedings in the future. Often, legal proceedings take place several years after the event. Not only will your PCR serve as your proof that you adhered to the standard of care, it also may jog your memory as to the events in question. Professional: Your PCR may be viewed by several people: hospital staff, quality improvement committees, supervisors, attorneys, the media, the patient and/or the patient’s family. Write your report in a professional manner, avoiding any remarks that might be construed as derogatory. A seemingly innocent phrase or use of jargon may come back to haunt you at a later date.Complete: The PCR should be precise and comprehensive. Include all relevant information that might be pertinent now or at a later date. Exclude all superfluous information. You should complete both the check box and the narrative portion of the PCR. The narrative is the core of the PCR. INCLUDE pertinent POSITIVES and NEGATIVES… Accurate: Correct spelling and grammar, as well as use of only approved abbreviations and acronyms are essential. Misspelled words may lose their meaning, or worse, be used in court as “proof” if bad care. Non-approved abbreviations may be misinterpreted. Several acronyms have more than one meaning – it is best to utilize only acronyms and/or abbreviations that have been approved by the State or the EMS agency. Legible: Penmanship must be neat, as several people may rely on the information contained in your report. Also, you might be called upon to review your PCR for legal proceedings in the future. Often, legal proceedings take place several years after the event. Not only will your PCR serve as your proof that you adhered to the standard of care, it also may jog your memory as to the events in question. Professional: Your PCR may be viewed by several people: hospital staff, quality improvement committees, supervisors, attorneys, the media, the patient and/or the patient’s family. Write your report in a professional manner, avoiding any remarks that might be construed as derogatory. A seemingly innocent phrase or use of jargon may come back to haunt you at a later date.

    63. General PCR Guidelines Legible handwriting Correct grammar and spelling Be: Objective Brief Accurate Clear Importance of Legible Handwriting and Correct Spelling and Grammar This is important for those reading the chart – especially attorneys. It is not uncommon to attempt to draw a connection in court between bad handwriting, spelling, or grammar and bad patient care. Most EMS cases do not go to court for 4-5 years after the event. Remember, your PCR is your only proof that you adhered to the standard of care. Be Objective Do not prejudge What is the worst thing that could be going on? Be without bias or prejudice Chronic patients or abusers of the system have real injuries as well Be Brief State things concisely Use short, succinct sentences “KISS” – “Keep it simple simon” Avoid long-winded statements Use only approved abbreviations (approved list appears at the end of this document) Be Accurate Never falsify, exaggerate, or make up data e.g. If you did not check pupils, do not document size and reactivity Document only objective information in a factual manner Be Clear Avoid vague notes Avoid shifts from present to past tense Be legible!Importance of Legible Handwriting and Correct Spelling and Grammar This is important for those reading the chart – especially attorneys. It is not uncommon to attempt to draw a connection in court between bad handwriting, spelling, or grammar and bad patient care. Most EMS cases do not go to court for 4-5 years after the event. Remember, your PCR is your only proof that you adhered to the standard of care. Be Objective Do not prejudge What is the worst thing that could be going on? Be without bias or prejudice Chronic patients or abusers of the system have real injuries as well Be Brief State things concisely Use short, succinct sentences “KISS” – “Keep it simple simon” Avoid long-winded statements Use only approved abbreviations (approved list appears at the end of this document) Be Accurate Never falsify, exaggerate, or make up data e.g. If you did not check pupils, do not document size and reactivity Document only objective information in a factual manner Be Clear Avoid vague notes Avoid shifts from present to past tense Be legible!

    64. Changes to the PCR DO NOT use “white out” or any correction fluid or tape DO NOT try to obliterate or destroy information, it gives the impression of covering up malpractice DO draw a single line through the mistake, write “error” above the mistake, date and initial it, and proceed with your documentation DO NOT leave blank or empty lines or spaces!

    65. Addendums to the PCR If applicable, a separate, carbonless lined sheet, attached as an “Addendum” may be included with the PCR. The addendum shall be a two-copy form and shall be routed in the following manner: Top (original) copy shall be retained by the EMS agency Second copy shall be retained by the receiving hospital/facility The addendum shall be numbered by the provider to correspond with the preprinted serial number on the PCR shall be submitted. Many agencies use a second PCR as the addendum and route the copies in the same manner as the original PCR. Just make sure you clearly label it as an addendum (as the “new” PCR will also have a PCR number).Many agencies use a second PCR as the addendum and route the copies in the same manner as the original PCR. Just make sure you clearly label it as an addendum (as the “new” PCR will also have a PCR number).

    66. Addendums to the PCR The addendum shall also contain: The date of the call The provider license number(s) The signature of the reporting provider(s) A sequential number for each page, as well as the total number of pages (e.g. “page 3 of 4”)

    67. What to Write in a PCR Anything you did for the patient & their response Anything you found during your assessment Pertinent + and - findings How you found the patient Where you left the patient Condition of the patient upon termination of care PIVs patent? MAE=x4? ETT position verified? Anything unusual with the call Who started care before you arrived If you did it, you should write it (& vice versa)

    68. “Within Normal Limits” Or “We Never Looked” ???????

    69. What NOT to Write in a PCR Any foul or objectionable language Anything that could be considered as libel Example: “He was drunk.” It is far better to write objective comments, such as: “Patient had odor of intoxicating substance on breath.” “Patient admits to drinking two beers.” “Patient unable to stand on his own without staggering and visual hallucinations.” Do not write on anything you have lying on top of a PCR because it will copy through onto the PCR, obscuring your report

    70. Refusal Documentation Patients ABLE to refuse care include: Competent individuals – defined as the ability to understand the nature and consequences of their actions AND Adult – defined as 18 years of age or older, except: An emancipated minor A married minor A minor in the military

    71. Refusal Documentation Patients NOT ABLE to refuse care include: Patients in whom the severity of their condition prevents them from making an informed, rational decision regarding their medical care. Altered level on consciousness (head injury, EtOH, hypoxia) Suicide (attempts or verbalizes) Severely altered vital signs Mental retardation and/or deficiency Any patient who makes clearly irrational decisions in the presence of an obvious potentially life or limb threatening injury, including persons who are emotionally unstable Any patient who is deemed a danger to self or others (under protective custody) Not acting as a “reasonable and prudent” person would, given the same circumstances Under age 18 (except as denoted above)

    72. Refusal Procedure Perform a complete exam with vitals If refused, document this Determine if the patient is competent to refuse Ensure the pt or responsible party: Has been told of his/her condition Understands the risks or refusal Assumes all risk & releases EMS from liability Understands he/she can call you back anytime It is important to note that a PCR that fails to document an orientation level or a physical assessment does not verify that the standard of care was met. Other than a tool for communicating credibility and clinical competency, the PCR can be used to document the patient’s verbal responses and interactions with those attempting to provide care. Quotes from the patient, especially if they are hostile in nature, can potentially speak volumes to a jury about the potential character of the patient. According to “EMS and the Law, A Legal Handbook for EMS Personnel” (Goldstein, A. Fairfield: Prentice-Hall, 1983), all patient refusals should be accompanied with a written release that, at a minimum, contains the following: The patient has been told of his or her condition The patient understands the risks of refusal The patient refuses transport (or whatever assistance was offered) The patient assumes all risks The patient releases EMS personnel from liability Even so, this may not be enough! Refusals of medical care in the prehospital setting occur at a relatively high rate and non-transport of a patient is the most common prehospital care event leading to litigation. Oftentimes, patients are unable to recall instructions and the risks as explained to them by EMS personnel. Cases of informed consent are the most common ethical conflict prehospital providers face. Experts recommend the following twelve items be included in refusal documentation: Physical examination to include vital signs History of event and prior medical history to include medications obtained Patient or decision-maker determined to be legally capable of refusing medical care Risks of refusal of medical care and transportation explained Patient clearly offered medical care and/or transportation Refusal of Care Form prepared, explained, signed, and witnessed Patient confirmed to have meaningful understanding of the risks and benefits involved in the medical care decision Patient advised to seek medical attention for complaint Patient advised to call 911 for medical attention if condition continues or worsens Base consultation occurred according to local policy Supervisor was notified if any of the above was not accomplished It is important to note that a PCR that fails to document an orientation level or a physical assessment does not verify that the standard of care was met. Other than a tool for communicating credibility and clinical competency, the PCR can be used to document the patient’s verbal responses and interactions with those attempting to provide care. Quotes from the patient, especially if they are hostile in nature, can potentially speak volumes to a jury about the potential character of the patient. According to “EMS and the Law, A Legal Handbook for EMS Personnel” (Goldstein, A. Fairfield: Prentice-Hall, 1983), all patient refusals should be accompanied with a written release that, at a minimum, contains the following: The patient has been told of his or her condition The patient understands the risks of refusal The patient refuses transport (or whatever assistance was offered) The patient assumes all risks The patient releases EMS personnel from liability Even so, this may not be enough! Refusals of medical care in the prehospital setting occur at a relatively high rate and non-transport of a patient is the most common prehospital care event leading to litigation. Oftentimes, patients are unable to recall instructions and the risks as explained to them by EMS personnel. Cases of informed consent are the most common ethical conflict prehospital providers face. Experts recommend the following twelve items be included in refusal documentation: Physical examination to include vital signs History of event and prior medical history to include medications obtained Patient or decision-maker determined to be legally capable of refusing medical care Risks of refusal of medical care and transportation explained Patient clearly offered medical care and/or transportation Refusal of Care Form prepared, explained, signed, and witnessed Patient confirmed to have meaningful understanding of the risks and benefits involved in the medical care decision Patient advised to seek medical attention for complaint Patient advised to call 911 for medical attention if condition continues or worsens Base consultation occurred according to local policy Supervisor was notified if any of the above was not accomplished

    73. Narrative Charting

    74. Subjective Any information you are able to elicit while taking the patient’s history: Chief Complaint (CC) History of Present Illness (HPI) “OPQRST – AS/PN” Past Medical & Surgical History Meds and Allergies SUBJECTIVE: what they tell you… Chief Complaint (CC): What the patient tells you the problem is. Example: “I have pain in my chest.” Use quotes whenever possible. History of Present Illness (HPI): For most chief complaints, the “OPQRST - ASPN” pneumonic may help the provider recall important questions to ask the patient. Remember to ask open-ended questions: “What does the pain feel like?” NOT “Is it sharp?” O – Onset Did the problem develop suddenly or gradually? What was the patient doing when it started? P – Provoke and Palliate Provoke: Does anything make the pain worse? Often, movement, deep inspiration, etc. can intensify pain. Exertion can intensify respiratory difficulty. Palliate: Does anything make the pain better? Did the patient take any medication prior to your arrival – bronchodilators, nitroglycerine, etc.? If so, did it help? Did the patient change position – e.g. sitting bolt upright? If so, did it help? Q – Quality: What does it feel like? It is important to ask open-ended questions, not questions where the patient can answer “yes” or “no”. Example: “What does it feel like?” NOT “Is it sharp?” Quote the patient’s description in the PCR. R – Region and Radiation: Where is the symptom located? You can ask the patient with pain to point to where it hurts. Does the symptom move/migrate/radiate anywhere else? S – Severity: Number scale from 0-10. 0 = no pain, 10 = the worst pain the patient has ever experienced. If the patient can not understand the 0-10 scale, try using “mild, moderate, or severe”. Look at the patient’s appearance – are they grimacing and diaphoretic? With children, you can use the “faces” scale – ask the child to point to the face diagram that looks like how they feel T – Time: When did the symptoms begin? Is it constant or intermittent? How long has it lasted? Any previous episodes? AS – Associated Symptoms Example: In the patient with chest pain, inquire about associated shortness of breath, nausea, dizziness, etc. PN – Pertinent Negatives Are any likely associated symptoms absent? This information might help rule out a particular illness or injury. Example: the patient with chest pain who does not complain of any shortness of breath, nausea, or dizziness but who does complain of increased pain with palpation or movement. Example: “Sudden onset chest pain while walking to mailbox. Pain worsened while walking inside and got slightly better with rest. Patient took three sublingual nitroglycerine tablets without any relief. Patient states it feels like a horse is sitting on his chest. Pain is sub-sternal, with radiation into the right side of the jaw. Patient rates pain a 5/10. Symptoms present for 20 minutes now, constant. Associated with slight nausea and shortness of breath.” Past Medical and Surgical History (PH) Example: Patient has a history of angina and insulin dependant diabetes mellitus.SUBJECTIVE: what they tell you… Chief Complaint (CC): What the patient tells you the problem is. Example: “I have pain in my chest.” Use quotes whenever possible. History of Present Illness (HPI): For most chief complaints, the “OPQRST - ASPN” pneumonic may help the provider recall important questions to ask the patient. Remember to ask open-ended questions: “What does the pain feel like?” NOT “Is it sharp?” O – Onset Did the problem develop suddenly or gradually? What was the patient doing when it started? P – Provoke and Palliate Provoke: Does anything make the pain worse? Often, movement, deep inspiration, etc. can intensify pain. Exertion can intensify respiratory difficulty. Palliate: Does anything make the pain better? Did the patient take any medication prior to your arrival – bronchodilators, nitroglycerine, etc.? If so, did it help? Did the patient change position – e.g. sitting bolt upright? If so, did it help? Q – Quality: What does it feel like? It is important to ask open-ended questions, not questions where the patient can answer “yes” or “no”. Example: “What does it feel like?” NOT “Is it sharp?” Quote the patient’s description in the PCR. R – Region and Radiation: Where is the symptom located? You can ask the patient with pain to point to where it hurts. Does the symptom move/migrate/radiate anywhere else? S – Severity: Number scale from 0-10. 0 = no pain, 10 = the worst pain the patient has ever experienced. If the patient can not understand the 0-10 scale, try using “mild, moderate, or severe”. Look at the patient’s appearance – are they grimacing and diaphoretic? With children, you can use the “faces” scale – ask the child to point to the face diagram that looks like how they feel T – Time: When did the symptoms begin? Is it constant or intermittent? How long has it lasted? Any previous episodes? AS – Associated Symptoms Example: In the patient with chest pain, inquire about associated shortness of breath, nausea, dizziness, etc. PN – Pertinent Negatives Are any likely associated symptoms absent? This information might help rule out a particular illness or injury. Example: the patient with chest pain who does not complain of any shortness of breath, nausea, or dizziness but who does complain of increased pain with palpation or movement. Example: “Sudden onset chest pain while walking to mailbox. Pain worsened while walking inside and got slightly better with rest. Patient took three sublingual nitroglycerine tablets without any relief. Patient states it feels like a horse is sitting on his chest. Pain is sub-sternal, with radiation into the right side of the jaw. Patient rates pain a 5/10. Symptoms present for 20 minutes now, constant. Associated with slight nausea and shortness of breath.” Past Medical and Surgical History (PH) Example: Patient has a history of angina and insulin dependant diabetes mellitus.

    75. Objective General Impression Primary Assessment ABCDE Secondary Assessment Head to Toe Exam OBJECTIVE: what you see… This includes your general impression and any data you find through inspection, palpation, auscultation, and percussion while performing your physical assessment of the patient. A Head-to-Toe approach can help with a systematic and thorough assessment. Example: General Impression: The patient presents in moderate distress, sitting upright on his living room couch. Vital signs: BP 146/82; Pulse 82, strong and regular at the radial site; Respirations 18, slightly labored. Neuro: Awake, alert, oriented x4. Pupils PERRLA @ 4mm. MAE =x4. HEENT: No signs of trauma Neck: Trachea midline, no JVD Chest: Lung sounds clear, equal bilateral. Pulse oximeter 98% on 4 lpm via NC. Cardiac monitor shows sinus rhythm without ectopy. Abdomen: Soft, non-tender. Bowel sounds present x4 quadrants. c/o slight nausea, no emesis at present. GI/GU/Pelvis: Stable pelvis, no changes in bowel or bladder habits. Extremities: CMS present in all extremities. Pulses 2+ radial and pedal, no peripheral edema.OBJECTIVE: what you see… This includes your general impression and any data you find through inspection, palpation, auscultation, and percussion while performing your physical assessment of the patient. A Head-to-Toe approach can help with a systematic and thorough assessment. Example: General Impression: The patient presents in moderate distress, sitting upright on his living room couch. Vital signs: BP 146/82; Pulse 82, strong and regular at the radial site; Respirations 18, slightly labored. Neuro: Awake, alert, oriented x4. Pupils PERRLA @ 4mm. MAE =x4. HEENT: No signs of trauma Neck: Trachea midline, no JVD Chest: Lung sounds clear, equal bilateral. Pulse oximeter 98% on 4 lpm via NC. Cardiac monitor shows sinus rhythm without ectopy. Abdomen: Soft, non-tender. Bowel sounds present x4 quadrants. c/o slight nausea, no emesis at present. GI/GU/Pelvis: Stable pelvis, no changes in bowel or bladder habits. Extremities: CMS present in all extremities. Pulses 2+ radial and pedal, no peripheral edema.

    76. Assessment Field Diagnosis What you believe the problem to be Working diagnosis Example: “Chest pain, R/O MI” ASSESSMENT: What you think the problem/diagnosis is… This is where you document what you believe the patient’s problem to be. This is also known as your “working diagnosis”, “field diagnosis”, or “impression”. Example: “chest pain, rule out unstable angina versus acute MI”ASSESSMENT: What you think the problem/diagnosis is… This is where you document what you believe the patient’s problem to be. This is also known as your “working diagnosis”, “field diagnosis”, or “impression”. Example: “chest pain, rule out unstable angina versus acute MI”

    77. Plan / Management Treatment Patient Response Example: “Patient placed on O2 at 4lpm by NC and placed on the cardiac monitor. Medical control contacted, and the following orders received from Dr. Smith: Nitroglycerine sublingual x3, 5 minutes apart for continued chest pain and BP >90/60. If no relief from nitroglycerine, administer morphine 2 mg SIVP, titrated to a maximum of 10 mg for continued chest pain and BP >90/60.” PLAN/MANAGEMENT: What you plan to do about the problem & what the pt’s response… Record what you plan on doing or what you did for the patient, from start to finish. This includes how you packaged and moved the patient to your stretcher and ambulance. List any interventions initiated prior to contacting your medical control physician. For example, did you apply oxygen and start an IV? Describe any orders from your medical control physician, and include his or her name. Describe how you transported the patient and the effect of any interventions (treatment modalities, medication administration, etc.) you performed. Include any ingoing assessments/reassessments and any changes in the patient’s condition. Finally, document the patient’s condition upon arrival to the hospital and who assumed care of the patient. If you have intubated the patient or started an IV, document proper placement or patency at hand-off. Example: “Patient placed on O2 at 4lpm by NC and placed on the cardiac monitor. Medical control contacted, and the following orders received from Dr. Smith: Nitroglycerine sublingual x3, 5 minutes apart for continued chest pain and BP >90/60. If no relief from nitroglycerine, administer morphine 2 mg SIVP, titrated to a maximum of 10 mg for continued chest pain and BP >90/60.” **An important component of documentation not directly addressed by the “SOAP” pneumonic is reevaluation, or patient response to plan/treatment. It is crucial to document this aspect of care! For example: “chest pain decreased from 4/10 to 1/10 with O2.”PLAN/MANAGEMENT: What you plan to do about the problem & what the pt’s response… Record what you plan on doing or what you did for the patient, from start to finish. This includes how you packaged and moved the patient to your stretcher and ambulance. List any interventions initiated prior to contacting your medical control physician. For example, did you apply oxygen and start an IV? Describe any orders from your medical control physician, and include his or her name. Describe how you transported the patient and the effect of any interventions (treatment modalities, medication administration, etc.) you performed. Include any ingoing assessments/reassessments and any changes in the patient’s condition. Finally, document the patient’s condition upon arrival to the hospital and who assumed care of the patient. If you have intubated the patient or started an IV, document proper placement or patency at hand-off. Example: “Patient placed on O2 at 4lpm by NC and placed on the cardiac monitor. Medical control contacted, and the following orders received from Dr. Smith: Nitroglycerine sublingual x3, 5 minutes apart for continued chest pain and BP >90/60. If no relief from nitroglycerine, administer morphine 2 mg SIVP, titrated to a maximum of 10 mg for continued chest pain and BP >90/60.” **An important component of documentation not directly addressed by the “SOAP” pneumonic is reevaluation, or patient response to plan/treatment. It is crucial to document this aspect of care! For example: “chest pain decreased from 4/10 to 1/10 with O2.”

    78. Narrative Charting Just another acronym to help providers remember what elements to chart on the PCRJust another acronym to help providers remember what elements to chart on the PCR

    79. CHART Chief Complaint History Assessment Rx Transport

    80. BREAK I/Cs may choose to go over each element of the PCR (for example with new providers) – also using actual PCRs from that service as additional teaching examples. For the TtT class, the focus will be on the 17 key trauma data elements the State is monitoring on/focusing on **At their agency, they will most likely choose to go through every field, not just the 17 key trauma data fields. **Encourage TtT participants to use actual PCRs from their agency as additional teaching examples. Can use overhead transparencies – use GOOD examples and examples which show OPPORTUNITIES FOR IMPROVEMENT. Mark out any names or other identifying information (cert #s, etc.)BREAK I/Cs may choose to go over each element of the PCR (for example with new providers) – also using actual PCRs from that service as additional teaching examples. For the TtT class, the focus will be on the 17 key trauma data elements the State is monitoring on/focusing on **At their agency, they will most likely choose to go through every field, not just the 17 key trauma data fields. **Encourage TtT participants to use actual PCRs from their agency as additional teaching examples. Can use overhead transparencies – use GOOD examples and examples which show OPPORTUNITIES FOR IMPROVEMENT. Mark out any names or other identifying information (cert #s, etc.)

    81. Demographics SERVICE Indicate responding EMS service name and NH License # (assigned by the BEMS). NH Lic # Indicate responding EMS service NH License # (assigned by the BEMS). DATE Month, Day, and Year Call # This is the number your service may have assigned to the call (local option). DISPATCHED TO Name of medical facility or physical address of the call (street, city, state). PATIENT NAME The patient’s full name (last, first, middle initial) and home telephone number on line 1. The physical address where the patient resides (city, 2-letter state abbreviation, zip code) on line 2. The patient’s full name and street address will be obscured on the BEMS copy of the PCR. D.O.B. Patient’s date of birth – month and day in 2-digit format (02, 12, etc.); year in 4-digit format (1955, 1999, etc.). AGE Patient’s age. Numeric value: 0-100. Sex Check the appropriate box with an “x”: “M” for male and “F” for female. Weight Enter a number and indicate if this is in pounds “lbs” or kilograms “kgs” (2.2 lbs = 1 kg). NOTE: it is generally more acceptable to document weight in kilograms. To calculate the # of KG, divide the patient’s weight in lbs by 2.2. Example: 220 lbs ? 2.2 = 100 kg. ** Patient Status Severity of patient injury or illness: 1: Emergent - A critically ill or injured patient who needs immediate attention and therapeutic intervention. Delays could potentially threaten life or function. Examples: cardiac arrest, respiratory arrest, acute chest pain with unstable vital signs, allergic reaction with acute respiratory distress and shock, severe shock, severe trauma (2 or more systems, gunshot wound, or stab wounds to head, neck, or truck; severe, uncontrolled hemorrhage). 2: Urgent - Less seriously ill, but requiring prompt therapeutic intervention to minimize the danger. Short delays in therapy will not seriously endanger patient’s condition. Examples: possible heart attack, congestive heart failure, asthmatic attack, overdose, hypo- or hyperglycemia, burns (2nd or 3rd degree over at least 20% of body surface or over entire face), grand mal seizures, serious fractures with possible internal injuries, hemorrhaging but with stable vital signs. 3: Non-Urgent - Not seriously ill or injured, but still requires transport to hospital. Medical attention required but with patient’s condition not endangered by even prolonged wait. 4: Does not require ambulance transport - Patient may not need medical attention. Patient’s condition does not require ambulance transport. ** Trauma Score Number achieved using the Revised Trauma Score (RTS). NOTIFY Name of person to notify (relationship and telephone number). ** Trauma Team Activated Check the box if the receiving hospital trauma team was activated for patient care.SERVICE Indicate responding EMS service name and NH License # (assigned by the BEMS). NH Lic # Indicate responding EMS service NH License # (assigned by the BEMS). DATE Month, Day, and Year Call # This is the number your service may have assigned to the call (local option). DISPATCHED TO Name of medical facility or physical address of the call (street, city, state). PATIENT NAME The patient’s full name (last, first, middle initial) and home telephone number on line 1. The physical address where the patient resides (city, 2-letter state abbreviation, zip code) on line 2. The patient’s full name and street address will be obscured on the BEMS copy of the PCR. D.O.B. Patient’s date of birth – month and day in 2-digit format (02, 12, etc.); year in 4-digit format (1955, 1999, etc.). AGE Patient’s age. Numeric value: 0-100. Sex Check the appropriate box with an “x”: “M” for male and “F” for female. Weight Enter a number and indicate if this is in pounds “lbs” or kilograms “kgs” (2.2 lbs = 1 kg). NOTE: it is generally more acceptable to document weight in kilograms. To calculate the # of KG, divide the patient’s weight in lbs by 2.2. Example: 220 lbs ? 2.2 = 100 kg. ** Patient Status Severity of patient injury or illness: 1: Emergent - A critically ill or injured patient who needs immediate attention and therapeutic intervention. Delays could potentially threaten life or function. Examples: cardiac arrest, respiratory arrest, acute chest pain with unstable vital signs, allergic reaction with acute respiratory distress and shock, severe shock, severe trauma (2 or more systems, gunshot wound, or stab wounds to head, neck, or truck; severe, uncontrolled hemorrhage). 2: Urgent - Less seriously ill, but requiring prompt therapeutic intervention to minimize the danger. Short delays in therapy will not seriously endanger patient’s condition. Examples: possible heart attack, congestive heart failure, asthmatic attack, overdose, hypo- or hyperglycemia, burns (2nd or 3rd degree over at least 20% of body surface or over entire face), grand mal seizures, serious fractures with possible internal injuries, hemorrhaging but with stable vital signs. 3: Non-Urgent - Not seriously ill or injured, but still requires transport to hospital. Medical attention required but with patient’s condition not endangered by even prolonged wait. 4: Does not require ambulance transport - Patient may not need medical attention. Patient’s condition does not require ambulance transport. ** Trauma Score Number achieved using the Revised Trauma Score (RTS). NOTIFY Name of person to notify (relationship and telephone number). ** Trauma Team Activated Check the box if the receiving hospital trauma team was activated for patient care.

    82. CC & HPI CHIEF COMPLAINT Problem as stated by the patient or a person competent to speak on the patient’s behalf. Be brief. Consider using quotation marks:“My chest hurts.” “I can’t breath.” “I can’t stop throwing up.” “She just passed out.” “I don’t feel well.” “My leg was run over by a car.” “I was just minding my own business when I got shot in the leg.” Bystander states “She fell out of the car”. Mom states “She turned blue while eating a hot dog.” HX PRESENT ILLNESS/ MECHANISM OF INJURY History or present illness or description of circumstances. This is where the provider elaborates on the chief complaint.. Example: the “OPQRST – ASPN” pneumonic Mechanism of injury: Specify cause of trauma.CHIEF COMPLAINT Problem as stated by the patient or a person competent to speak on the patient’s behalf. Be brief. Consider using quotation marks:“My chest hurts.” “I can’t breath.” “I can’t stop throwing up.” “She just passed out.” “I don’t feel well.” “My leg was run over by a car.” “I was just minding my own business when I got shot in the leg.” Bystander states “She fell out of the car”. Mom states “She turned blue while eating a hot dog.” HX PRESENT ILLNESS/ MECHANISM OF INJURY History or present illness or description of circumstances. This is where the provider elaborates on the chief complaint.. Example: the “OPQRST – ASPN” pneumonic Mechanism of injury: Specify cause of trauma.

    83. Past Medical History Allergies Any substance, including medications and herbal remedies, to which patient has had an adverse reaction. Meds Rx All medications, including over the counter and herbal remedies, patient is currently taking. Pertinent Med/Surg. Hx Any medical or surgical history that has relationship or effect on patient’s condition. Medical I.D. for: Any medical or surgical history noted on a medic alert bracelet, necklace, etc. that has relationship or effect on patient’s condition. Patient’s MD Patient’s personal physician.Allergies Any substance, including medications and herbal remedies, to which patient has had an adverse reaction. Meds Rx All medications, including over the counter and herbal remedies, patient is currently taking. Pertinent Med/Surg. Hx Any medical or surgical history that has relationship or effect on patient’s condition. Medical I.D. for: Any medical or surgical history noted on a medic alert bracelet, necklace, etc. that has relationship or effect on patient’s condition. Patient’s MD Patient’s personal physician.

    84. EMS Response Times EMS RESPONSE TIMES Use Military time (2400 clock) – always four digits. Range will be 0000-2400. Here are some examples: 12:01 am = 0001 6:01 am = 0601 12:01 pm = 1201 6:01 pm = 1801 9:01 pm = 2101 11:59 pm = 2359 Midnight = 2400 The times you enter on the PCR are considered the official times of the incident. Ensure their accuracy! Whenever possible, record all times from the same clock. When this is not possible, synchronize watches/clocks you use.EMS RESPONSE TIMES Use Military time (2400 clock) – always four digits. Range will be 0000-2400. Here are some examples: 12:01 am = 0001 6:01 am = 0601 12:01 pm = 1201 6:01 pm = 1801 9:01 pm = 2101 11:59 pm = 2359 Midnight = 2400 The times you enter on the PCR are considered the official times of the incident. Ensure their accuracy! Whenever possible, record all times from the same clock. When this is not possible, synchronize watches/clocks you use.

    85. Vital Signs TIME Use 24-hour (military) time. L.O.C. Circle One: A: Alert and oriented (person, place, and day) V: Responds to verbal stimuli (call patient’s name); Patient can verbalize, but is not oriented to person, place, and day P: Responds to painful stimuli only (pinch, nail bed pressure) U: Unresponsive PULSE Enter rate (beats per minute). Check the quality: Regular Irregular Strong Weak BP Enter systolic and diastolic numbers. If taken by palpation, enter “P” in place of diastolic pressure. Examples:124/7890/P RESPIRATIONS Enter rate (breaths per minute). Check the quality: Normal Abnormal Labored Shallow **Ideally, there should be at least two full sets of vital signs. **Document orthostatic/postural vital signs as appropriate and indicate patient position by drawing stick figure: supine, sitting, standing. **If the patient is on the cardiac monitor, describe the rhythm and attach a rhythm strip TIME Use 24-hour (military) time. L.O.C. Circle One: A: Alert and oriented (person, place, and day) V: Responds to verbal stimuli (call patient’s name); Patient can verbalize, but is not oriented to person, place, and day P: Responds to painful stimuli only (pinch, nail bed pressure) U: Unresponsive PULSE Enter rate (beats per minute). Check the quality: Regular Irregular Strong Weak BP Enter systolic and diastolic numbers. If taken by palpation, enter “P” in place of diastolic pressure. Examples:124/7890/P RESPIRATIONS Enter rate (breaths per minute). Check the quality: Normal Abnormal Labored Shallow **Ideally, there should be at least two full sets of vital signs. **Document orthostatic/postural vital signs as appropriate and indicate patient position by drawing stick figure: supine, sitting, standing. **If the patient is on the cardiac monitor, describe the rhythm and attach a rhythm strip

    86. Lung Sounds, Pupils, Skin, Temp LUNG SOUNDS Record presence of absence of lung sounds in both lungs. Check applicable descriptors for each lung: Clear Absent Stridor Rales Rhonchi Wheezes PUPILS Check all that apply for each eye: Reactive Unreactive Constricted Dilated Check if applicable for both eyes: Unequal Disconjugate Document size (in mm) of each pupil. Use the diagram as a guide. SKIN Check all that apply: Normal Cyanotic Moist Flushed Pale TEMPERATURE: Temperature is an essential vital sign to record. Check the applicable box: Normal Warm/Hot Cool/Cold Document the patient’s actual temperature (number) and indicate if it is in Celsius or Fahrenheit. Trauma Patients who are allowed to get hypothermic do worse! LUNG SOUNDS Record presence of absence of lung sounds in both lungs. Check applicable descriptors for each lung: Clear Absent Stridor Rales Rhonchi Wheezes PUPILS Check all that apply for each eye: Reactive Unreactive Constricted Dilated Check if applicable for both eyes: Unequal Disconjugate Document size (in mm) of each pupil. Use the diagram as a guide. SKIN Check all that apply: Normal Cyanotic Moist Flushed Pale TEMPERATURE: Temperature is an essential vital sign to record. Check the applicable box: Normal Warm/Hot Cool/Cold Document the patient’s actual temperature (number) and indicate if it is in Celsius or Fahrenheit. Trauma Patients who are allowed to get hypothermic do worse!

    87. Narrative The narrative portion of the chart should include a complete chronological flow of events, including times, treatment rendered, and patient condition or response to each treatment rendered. In the narrative, be sure to include all pertinent positives and negatives with regard to the patient’s condition. NARRATIVE Time Use 24-hour (military) clock. Treatment Examples include: Oxygen at 4 lpm by NC Full spinal immobilization with LSB, head bead, c-collar, and straps x3Morphine 3 mg IVP Results/Observations Record the patient’s response to any treatment. Examples include:SpO2 increased to 98% after O2 applied MAE=x4 before and after spinal immobilization Chest pain decreased from 5/10 to 2/10 with Morphine NH ALS# Provider number of the person who performed the treatment or intervention Medical Control Document the name of the Physician and the Hospital contacted for orders. Check whether treatment was rendered based on a verbal order or a standing order. If the patient is placed on the cardiac monitor, describe the ECG and staple the ECG strip to the white (hospital) copy of the PCR. The narrative portion of the chart should include a complete chronological flow of events, including times, treatment rendered, and patient condition or response to each treatment rendered. In the narrative, be sure to include all pertinent positives and negatives with regard to the patient’s condition. NARRATIVE Time Use 24-hour (military) clock. Treatment Examples include: Oxygen at 4 lpm by NC Full spinal immobilization with LSB, head bead, c-collar, and straps x3Morphine 3 mg IVP Results/Observations Record the patient’s response to any treatment. Examples include:SpO2 increased to 98% after O2 applied MAE=x4 before and after spinal immobilization Chest pain decreased from 5/10 to 2/10 with Morphine NH ALS# Provider number of the person who performed the treatment or intervention Medical Control Document the name of the Physician and the Hospital contacted for orders. Check whether treatment was rendered based on a verbal order or a standing order. If the patient is placed on the cardiac monitor, describe the ECG and staple the ECG strip to the white (hospital) copy of the PCR.

    88. Ambulance Crew & License Number, Signature AMBULANCE CREW and LICENSE # Enter each crew member’s name and license number in the spaces provided. Signature, Primary Care Attendant Signature of the primary care provider. Routing if the PCR is as noted: Original – retained by the service White Copy – Hospital copy Yellow Copy – BEMS copy Pink (not Green) Copy – EMS Hospital CoordinatorAMBULANCE CREW and LICENSE # Enter each crew member’s name and license number in the spaces provided. Signature, Primary Care Attendant Signature of the primary care provider. Routing if the PCR is as noted: Original – retained by the service White Copy – Hospital copy Yellow Copy – BEMS copy Pink (not Green) Copy – EMS Hospital Coordinator

    89. First Responder Information First Responder Service Identify EMS First Response Service (Rescue Squad, FAST Squad, etc.) by name. Arrival Time Use 24-hour (military) clock. Service # NH EMS service number. Prior Care by: Indicate, by checking the appropriate box, the first person to provide any patient care: First Responder MD/RN Fire Police Bystander Aid Given: Indicate, by checking the appropriate box, what treatment was rendered prior to arrival of the ambulance: Moved Patient CPR Other (briefly describe)First Responder Service Identify EMS First Response Service (Rescue Squad, FAST Squad, etc.) by name. Arrival Time Use 24-hour (military) clock. Service # NH EMS service number. Prior Care by: Indicate, by checking the appropriate box, the first person to provide any patient care: First Responder MD/RN Fire Police Bystander Aid Given: Indicate, by checking the appropriate box, what treatment was rendered prior to arrival of the ambulance: Moved Patient CPR Other (briefly describe)

    90. Type of Ambulance Response TO Scene Check each that applies. FROM scene Check each that applies.TO Scene Check each that applies. FROM scene Check each that applies.

    91. Type of Call, MOI, Scene TYPE OF CALL Check all that apply. If “other”, please specify in writing. MECHANISM OF INJURY Check all that apply. If “other”, please specify in writing. If vehicular trauma, indicate (write in) type of vehicle – i.e. car, pick-up truck, motorcycle, bicycle, etc. Indicate safety restraints used or deployed. SCENE Check all that apply. If “other”, please specify in writing. Check Hazardous Materials only if involved in the incident. Indicate whether the patient was AT WORK at the time of injury.TYPE OF CALL Check all that apply. If “other”, please specify in writing. MECHANISM OF INJURY Check all that apply. If “other”, please specify in writing. If vehicular trauma, indicate (write in) type of vehicle – i.e. car, pick-up truck, motorcycle, bicycle, etc. Indicate safety restraints used or deployed. SCENE Check all that apply. If “other”, please specify in writing. Check Hazardous Materials only if involved in the incident. Indicate whether the patient was AT WORK at the time of injury.

    92. Care Given Patient CARE GIVEN PATIENT Check all that apply. If “other care”, please specify in writing.CARE GIVEN PATIENT Check all that apply. If “other care”, please specify in writing.

    93. Signs & Symptoms by Site SIGNS AND SYMPTOMS BY SITE Mark ALL boxes that apply with an “x”.SIGNS AND SYMPTOMS BY SITE Mark ALL boxes that apply with an “x”.

    94. Signs & Symptoms by Type SIGNS AND SYMPTOMS BY TYPE Mark ALL boxes that apply with an “x”.SIGNS AND SYMPTOMS BY TYPE Mark ALL boxes that apply with an “x”.

    95. GCS & RTS This is perhaps the most confusing part of the PCR for most providers! The Glasgow Coma Scale (GCS) is an objective measure of the extent and progression of neurologic injury. The basis for the GCS is the response of the patient to the rescuer’s three specific requests: Eye Opening, Verbal Response, and Motor Response. The patient’s response is assigned a number, as outlined here. The higher the score, the more responsive the patient is to the rescuer’s commands. The highest score possible is 15; the lowest score possible is 3. It is important to note the GCS is based on the patient’s BEST response. The GCS scores the patient’s response in regard to the patient’s injuries, not to treatment (sedation, pain medication) rendered. **Over the next few slides: We will break down each aspect of the GCS (EVM) and then, using and example, calculate a patient’s GCS and RTS.This is perhaps the most confusing part of the PCR for most providers! The Glasgow Coma Scale (GCS) is an objective measure of the extent and progression of neurologic injury. The basis for the GCS is the response of the patient to the rescuer’s three specific requests: Eye Opening, Verbal Response, and Motor Response. The patient’s response is assigned a number, as outlined here. The higher the score, the more responsive the patient is to the rescuer’s commands. The highest score possible is 15; the lowest score possible is 3. It is important to note the GCS is based on the patient’s BEST response. The GCS scores the patient’s response in regard to the patient’s injuries, not to treatment (sedation, pain medication) rendered. **Over the next few slides: We will break down each aspect of the GCS (EVM) and then, using and example, calculate a patient’s GCS and RTS.

    96. GCS Eye The highest score (best possible response) to each response (eye, verbal, motor) is recorded and the three categories are totaled. Serial assessments are paramount to allow the patient’s response to be trended. The “Total GCS” number is then used to calculate the RTS (in trauma patients ONLY).The highest score (best possible response) to each response (eye, verbal, motor) is recorded and the three categories are totaled. Serial assessments are paramount to allow the patient’s response to be trended. The “Total GCS” number is then used to calculate the RTS (in trauma patients ONLY).

    97. GCS Verbal The highest score (best possible response) to each response (eye, verbal, motor) is recorded and the three categories are totaled. Serial assessments are paramount to allow the patient’s response to be trended. The “Total GCS” number is then used to calculate the RTS (in trauma patients ONLY).The highest score (best possible response) to each response (eye, verbal, motor) is recorded and the three categories are totaled. Serial assessments are paramount to allow the patient’s response to be trended. The “Total GCS” number is then used to calculate the RTS (in trauma patients ONLY).

    98. GCS Motor The highest score (best possible response) to each response (eye, verbal, motor) is recorded and the three categories are totaled. Serial assessments are paramount to allow the patient’s response to be trended. The “Total GCS” number is then used to calculate the RTS (in trauma patients ONLY). *Many people confuse “localizes” and “withdraws”, esp. with IV start…The highest score (best possible response) to each response (eye, verbal, motor) is recorded and the three categories are totaled. Serial assessments are paramount to allow the patient’s response to be trended. The “Total GCS” number is then used to calculate the RTS (in trauma patients ONLY). *Many people confuse “localizes” and “withdraws”, esp. with IV start…

    99. When documenting GCS in the narrative, it is important to break down the scores for each of the three parameters and also provide the total score. Using the example above, one would document: “GCS: 3-4-4=11”. This paints a much clearer picture than simply documenting “GCS 11”, which does not indicate which part of the GCS the patient lost points on for inappropriate responses. This also allows for much better trending of the patient’s responses over time. **Some would argue this is a “localizes” response to pain, rather than a “withdraws”… A true “localizes”, or higher level response, would be to use her other arm to try to remove the painful stimulus (your hand starting the IV)When documenting GCS in the narrative, it is important to break down the scores for each of the three parameters and also provide the total score. Using the example above, one would document: “GCS: 3-4-4=11”. This paints a much clearer picture than simply documenting “GCS 11”, which does not indicate which part of the GCS the patient lost points on for inappropriate responses. This also allows for much better trending of the patient’s responses over time. **Some would argue this is a “localizes” response to pain, rather than a “withdraws”… A true “localizes”, or higher level response, would be to use her other arm to try to remove the painful stimulus (your hand starting the IV)

    100. The total GCS score corresponds to a value on the Revised Trauma Score (RTS). The GCS is one of three values considered. The other two are systolic blood pressure and respiratory rate. Match the total “GCS Points” to the corresponding number on the RTS. Match the systolic BP and respiratory rate to the corresponding numerical value on the RTS. Add the numbers in each of the three categories to determine the patient’s RTS. Only trauma patients should have a calculated RTS. Patients with an RTS <11 should go to a Regional Trauma Hospital.The total GCS score corresponds to a value on the Revised Trauma Score (RTS). The GCS is one of three values considered. The other two are systolic blood pressure and respiratory rate. Match the total “GCS Points” to the corresponding number on the RTS. Match the systolic BP and respiratory rate to the corresponding numerical value on the RTS. Add the numbers in each of the three categories to determine the patient’s RTS. Only trauma patients should have a calculated RTS. Patients with an RTS <11 should go to a Regional Trauma Hospital.

    102. Billing Information Optional for agencies that do billingOptional for agencies that do billing

    103. Mileage START Enter odometer mileage at location vehicle was dispatched from. SCENE Enter odometer mileage at location of patient. DESTINATION Enter odometer mileage at patient’s destination. LOADED MILES Subtract on-scene reading from reading at destination to obtain “loaded miles”.START Enter odometer mileage at location vehicle was dispatched from. SCENE Enter odometer mileage at location of patient. DESTINATION Enter odometer mileage at patient’s destination. LOADED MILES Subtract on-scene reading from reading at destination to obtain “loaded miles”.

    104. Hospital Linkage Data Optional – for use by all hospitals in New Hampshire that receive emergency ambulance patients. This section is to be completed by the receiving hospital emergency department. Completion of this section is vital for assessment of EMS system performance and linkage of prehospital care and training data to patient outcome. Perhaps the most critical data item to be recorded is the Patient ID#. This number is essential to determine the overall impact of the EMS system upon patient outcome.Optional – for use by all hospitals in New Hampshire that receive emergency ambulance patients. This section is to be completed by the receiving hospital emergency department. Completion of this section is vital for assessment of EMS system performance and linkage of prehospital care and training data to patient outcome. Perhaps the most critical data item to be recorded is the Patient ID#. This number is essential to determine the overall impact of the EMS system upon patient outcome.

    105. Refusal of Care

    106. BREAKBREAK

    107. PCR Routing Top Copy EMS Unit 2nd Copy Receiving Hospital 3rd Copy NHBEMS 4th Copy Agency’s Hospital EMS Coordinator The top (original, white) copy is the agency’s official record of the service provided. This page may be utilized for billing and/or quality improvement purposes before becoming part of the agency’s permanent files. The second (also white) copy is the part of the patient’s official medical record and should be left with the patient at the receiving hospital or medical facility to be incorporated into the patient’s medical records. This copy should be delivered to the receiving hospital/facility upon delivery of the patient or within 24 hours of delivery of the patient if a subsequent emergency call or transfer necessitates a delay. The third (yellow) copy is the NHBEMS copy and must be forwarded to the BEMS by the 15th of the month following the month of the patient’s arrival at the receiving hospital/facility (e.g. by March 15th if the patient transfer occurred in February). The Bureau provides, at no cost to the units, the PCR forms and self-addressed, prepaid envelopes for use in submitting the PCR forms to the Bureau. If a unit or hospital/facility elects to submit the patient data electronically, the data shall be submitted on diskette(s). The fourth (pink) copy is for the EMS Hospital Coordinator. This copy should be delivered to the receiving hospital/facility upon delivery of the patient or within 24 hours of delivery of the patient if a subsequent emergency call or transfer necessitates a delay. The top (original, white) copy is the agency’s official record of the service provided. This page may be utilized for billing and/or quality improvement purposes before becoming part of the agency’s permanent files. The second (also white) copy is the part of the patient’s official medical record and should be left with the patient at the receiving hospital or medical facility to be incorporated into the patient’s medical records. This copy should be delivered to the receiving hospital/facility upon delivery of the patient or within 24 hours of delivery of the patient if a subsequent emergency call or transfer necessitates a delay. The third (yellow) copy is the NHBEMS copy and must be forwarded to the BEMS by the 15th of the month following the month of the patient’s arrival at the receiving hospital/facility (e.g. by March 15th if the patient transfer occurred in February). The Bureau provides, at no cost to the units, the PCR forms and self-addressed, prepaid envelopes for use in submitting the PCR forms to the Bureau. If a unit or hospital/facility elects to submit the patient data electronically, the data shall be submitted on diskette(s). The fourth (pink) copy is for the EMS Hospital Coordinator. This copy should be delivered to the receiving hospital/facility upon delivery of the patient or within 24 hours of delivery of the patient if a subsequent emergency call or transfer necessitates a delay.

    108. NHBEMS Copy PCR copies take up to 45 days to reach the Bureau They are then sent to the prison, where the information is keyed into a database Data is sent back to the Bureau, where it is entered into the existing database Delay of 18-24 months PCRs are provided free of charge to agencies at an annual cost to the BEMS of approximately $16,000. The PCRs are distributed through Field Offices to EMS agencies and hospitals. Once a PCR is generated, it is divided as follows: top copy to the EMS unit, second copy to the receiving hospital, third copy is returned to the Bureau of EMS, and the fourth copy is sent to the agency’s Hospital EMS Coordinator. According to Saf-C 5902.07 (f) “The third copy of the PCR form (sent) in person or by mail (to the Bureau with patient information removed), by the 15th of the month following the month of the patient’s arrival at the hospital/facility”. This causes a delay of forty-five days. Once received by the BEMS, the PCRs are sent to the New Hampshire Men’s Prison in Berlin where the information is hand keyed into a database. The annual cost is approximately $7,500. After the data is entered, it is placed onto floppy discs and returned to the BEMS to be imported into the existing database. Due to the logistics of the present system, available data for review is one to two years behind and reports are generated by specific request only. In the future, a computerized PCR system will allow for the analysis and reporting of real-time data.PCRs are provided free of charge to agencies at an annual cost to the BEMS of approximately $16,000. The PCRs are distributed through Field Offices to EMS agencies and hospitals. Once a PCR is generated, it is divided as follows: top copy to the EMS unit, second copy to the receiving hospital, third copy is returned to the Bureau of EMS, and the fourth copy is sent to the agency’s Hospital EMS Coordinator. According to Saf-C 5902.07 (f) “The third copy of the PCR form (sent) in person or by mail (to the Bureau with patient information removed), by the 15th of the month following the month of the patient’s arrival at the hospital/facility”. This causes a delay of forty-five days. Once received by the BEMS, the PCRs are sent to the New Hampshire Men’s Prison in Berlin where the information is hand keyed into a database. The annual cost is approximately $7,500. After the data is entered, it is placed onto floppy discs and returned to the BEMS to be imported into the existing database. Due to the logistics of the present system, available data for review is one to two years behind and reports are generated by specific request only. In the future, a computerized PCR system will allow for the analysis and reporting of real-time data.

    109. TEMSIS Real time Data Collection & Analysis Comprehensive statewide system Will support QA and CQI EMS Systems vary in their ability to collect patient and systems data and to put these data to use. No means currently exist to easily link disparate EMS databases to allow analysis at a local, state, and national level. For this reason, the National Assoc of State EMS Directors (NASEMSD) is working with NHTSA and HRSA to develop a national EMS database. Such a database would be useful in: developing nationwide EMS training curricula, evaluating patient and EMS system outcomes, facilitating research efforts, determining national fee schedules and reimbursement rates, addressing resources for disaster and domestic preparedness, and providing valuable information on other issues or areas of need related to EMS care. EMS providers are held accountable for their response times, quality of service, and medical care provided and for the cost or value of EMS to the patient and community. EMS providers are also required to prove their effect on patient outcome as a justification for their existence. As part of the health-care system, EMS personnel must interact at the local hospital, regional, state, and federal levels through the exchange of information. To facilitate this exchange of information, EMS systems must have methods of collecting and analyzing data and sharing it with others. The development of local and state EMS information systems is an ongoing process that should facilitate improved EMS systems and improved patient care and should culminate in the establishment of a national EMS database. www.nemsis.org www.nedarc.orgEMS Systems vary in their ability to collect patient and systems data and to put these data to use. No means currently exist to easily link disparate EMS databases to allow analysis at a local, state, and national level. For this reason, the National Assoc of State EMS Directors (NASEMSD) is working with NHTSA and HRSA to develop a national EMS database. Such a database would be useful in: developing nationwide EMS training curricula, evaluating patient and EMS system outcomes, facilitating research efforts, determining national fee schedules and reimbursement rates, addressing resources for disaster and domestic preparedness, and providing valuable information on other issues or areas of need related to EMS care. EMS providers are held accountable for their response times, quality of service, and medical care provided and for the cost or value of EMS to the patient and community. EMS providers are also required to prove their effect on patient outcome as a justification for their existence. As part of the health-care system, EMS personnel must interact at the local hospital, regional, state, and federal levels through the exchange of information. To facilitate this exchange of information, EMS systems must have methods of collecting and analyzing data and sharing it with others. The development of local and state EMS information systems is an ongoing process that should facilitate improved EMS systems and improved patient care and should culminate in the establishment of a national EMS database. www.nemsis.org www.nedarc.org

    110. Why do we collect data? Benefit patient care Provide feedback to the EMS agency/provider Evaluate system performance Determine if the patient treatment protocols are working for the patient population served Design injury prevention programs Perform quality assurance Outline opportunities for improvement in data collection and the reporting system We want to know if what we are doing works (Evidence Based Medicine), NOT “because that is the way we have always done it”.We want to know if what we are doing works (Evidence Based Medicine), NOT “because that is the way we have always done it”.

    111. Examples of Reports Response time Performance, such as ETI success rates Procedures, such as number of IVs per provider per year Number of CPR calls

    112. Difficulties… “Garbage in…garbage out.” Information collected must be complete and accurate or it will not be useful.

    113. 17 Key Trauma Data Fields On Scene Pt Status Pulse Resp Rate Systolic BP GCS Total GCS Eye GCS Motor GCS Verbal Diastolic BP RTS Total RTS GCS RTS Resp Rate RTS BP Trauma Patient? Temperature Trauma Team Activated? These are the 17 “Key Data Fields” emphasized in this presentation.These are the 17 “Key Data Fields” emphasized in this presentation.

    114. The data in the above study were based on 96,763 total EMS calls, 32.4% of which were trauma calls. The study of 17 key trauma fields on the PCR found compliance in trauma documentation on PCRs submitted to the BEMS ranged from 0-92.8%. On scene time was reported with the most regularity (92.8% of the time). Temperature was one of the variables that was not reported in any of the PCRs reviewed. Temperature is an important vital sign because many studies have shown increased death and disability if trauma patients are allowed to get hypothermic. The data in the above study were based on 96,763 total EMS calls, 32.4% of which were trauma calls. The study of 17 key trauma fields on the PCR found compliance in trauma documentation on PCRs submitted to the BEMS ranged from 0-92.8%. On scene time was reported with the most regularity (92.8% of the time). Temperature was one of the variables that was not reported in any of the PCRs reviewed. Temperature is an important vital sign because many studies have shown increased death and disability if trauma patients are allowed to get hypothermic.

    115. Approved Abbreviations A complete list is available in the accompanying Resource Guide

    116. Data Dictionary Clearly defines each data field and how to fill in the corresponding “box” on the PCR. Available through the State Office.

    117. Summary Trauma Systems Save Lives! Trauma Triage is a crucial component of the NH Trauma System. The Bureau of EMS is committed to getting the Right Patient to the Right Facility in the Right Time.

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