Emergency Department Trauma Flowsheet Documentation

1. Emergency Department Trauma Flowsheet Documentation Evelyn Clark-Kula, RN, BSN, Janice Gillespie, RN, Bridget Gaughan, RN, MSN, Sylvia Wright, RN, MSN, Kristi Dombrow, RN, BSN, and Karen Steed, RN, BSN Confidential: For Quality Improvement Purposes Only

2. Project Aim Statement • The Trauma QI Committee identified that certain key indicators were not consistently being documented on the trauma flowsheets. The aim of this project was to increase compliance by the Emergency Department nurses in documenting these indicators. Confidential: For Quality Improvement Purposes Only

3. Measurement Goal • All indicators >80% compliance per ACS (American College of Surgeons) criteria by February 1, 2008 Confidential: For Quality Improvement Purposes Only

4. Solutions Implemented • Monthly Trauma QI attendance at ED Clinical Operations Committee Meetings • Letters written to ED RNs who did not meet documentation indicators beginning 8/1/07 • Distribution of letters to ED Staff by ED Management Team • Education of ED staff by ED Educator and ED Management Team • Informal real-time chart review amongst fellow ED RNs and Management Team • Trauma Program Manager review of real-time trauma resuscitation documentation • Posting of flowsheet indicators on bedside tables in ED Trauma Bay Confidential: For Quality Improvement Purposes Only

5. Sample ED RN Letter Confidential-Quality Improvement Material Loyola University Medical Center Trauma Services Emergency Department RN Documentation MR# 0000000 Smith, John To: Debbie Reynolds, RN From: Jan Gillespie, RN Trauma Program Manager Trauma QI Committee Debbie, on 8/1/07 you helped care for the above mentioned patient. On the trauma flowsheet you documented when the Trauma Attending was called and when they answered, but not if they arrived or the time of their arrival – you left that space blank. If they do not arrive in the trauma bay a (-) should be placed in the arrival box – otherwise a time must be written when they arrive. To chart that the trauma team was present is not sufficient. In addition, the patient’s Intake & Output were not documented at the time of disposition. This is for educational purposes and trending. If you have any questions please call me at x73715, page me at 15768, or email me. On a positive note, you did chart the pt time of arrival in the box correctly, and the patient’s temperature. Attached please find a copy of the above mentioned flowsheet. Confidential: For Quality Improvement Purposes Only

6. Results • All indicators reached >80% goal in February of 2008 as reported at ED Clinical Operations Committee Meeting Confidential: For Quality Improvement Purposes Only

7. Documentation of Trauma Attending Arrival 100 90 80 70 60 Percent of charts with documentation of trauma attending arrival 50 40 July 2007 May 2007 June 2007 March 2008 August 2007 October 2007 January 2008 February 2008 November 2007 December 2007 September 2007 Month Mean = 77.55 Letters to staff initiated Confidential: For Quality Improvement Purposes Only

8. Documentation of Patient Arrival Time 104 102 100 98 96 94 Percentage of flowsheets with patient arrival time documented 92 90 July 2007 May 2007 April 2007 June 2007 March 2007 March 2008 August 2007 October 2006 January 2007 October 2007 January 2008 February 2007 February 2008 November 2007 November 2006 December 2006 December 2007 September 2006 September 2007 Month Letters to staff initiated Mean = 96.47 Confidential: For Quality Improvement Purposes Only

9. Documentation of IV Fluid Volume Infused 90 80 70 Mean = 60.00 60 50 Percentage of flowsheets with IV fluid volumes documented 40 30 July 2006 July 2007 May 2007 April 2007 June 2007 March 2007 March 2008 August 2006 August 2007 October 2006 January 2007 October 2007 January 2008 February 2007 February 2008 November 2007 November 2006 December 2006 December 2007 September 2006 September 2007 Month Letters to staff initiated Confidential: For Quality Improvement Purposes Only

10. Documentation of Output on Trauma Flowsheet 100 90 80 70 60 Mean = 58.45 50 40 Percent of Flowsheets with Output Documented 30 20 10 July 2007 May 2007 April 2007 June 2007 March 2007 March 2008 August 2006 August 2007 October 2006 January 2007 October 2007 January 2008 February 2007 February 2008 November 2007 November 2006 December 2006 December 2007 September 2006 September 2007 Month Letters to staff initiated Confidential: For Quality Improvement Purposes Only

11. Documentation of Temperature on Trauma Flowsheet 105 100 95 90 Percent of charts with temperature documented 85 80 July 2006 July 2007 May 2006 May 2007 April 2006 April 2007 June 2006 June 2007 March 2006 March 2007 March 2008 August 2006 August 2007 January 2006 October 2006 January 2007 October 2007 January 2008 February 2006 February 2007 February 2008 November 2007 November 2006 December 2006 December 2007 September 2006 September 2007 Month Mean = 93.22 Letters to staff initiated Confidential: For Quality Improvement Purposes Only

12. Analysis • Improved documentation of Trauma Attending Arrival, Patient Arrival, Temperature, and Intake/Output to greater than >80% goal • Greatest improvement was noticed after letters were sent to ED RNs Confidential: For Quality Improvement Purposes Only

13. Next Steps • Education of ED staff will remain continuous due to turnover of staff credentialed to care for trauma patients • In past years, decreased emphasis on documentation has resulted in poor compliance with specific indicators Confidential: For Quality Improvement Purposes Only