Transcript Trauma Registry: The Nuts & Bolts of Data Collection

Trauma Registry: The Nuts &
Bolts of Data Collection
Karla Bryan, RN, BSN
Trauma Coordinator
EIRMC
Trauma Resuscitation Overview
• Report received from EMS; trauma page goes
out
• Pt. arrives in ED
• Met by resuscitation team: at least 2 MDs, 2
RNs, Lab, X-ray, Respiratory Therapist,
Pharmacist, Scribe, House Supervisor, Social
Services, Security, CT Tech, EMS
• Assessment, stabilization, procedures, tests
(plain films/CT, angio, FAST)
What precludes thorough data
collection?
The Trauma Bay Environment
•
Recorder: Primary RN or dedicated recorder
•
The number of trauma team members in the room
•
Intense team activity: assessment, stabilization,
diagnostics
•
Charting after the fact
Recording Extremes:
• Difficult: Pt. arrives from MVC, ejected,
comatose, obvious open femur fx, open
tib/fib fx, distended abdomen, respiratory
distress
• Easy: Pt. arrives after being bucked off
horse, c/o sore back, obvious forearm fx,
no neuro deficits, VSS, alert/oriented.
Getting the Necessary Information
• Know what you need
ITR, ACS, NTDB
• Look in depth at ED chart for needed data elements
• Take information to your director
• Meet with ED Director/Manager: be prepared to show ITR
requirements, what is lacking on chart (if cues aren’t there,
info won’t be collected)
• Work with core group of ED RNs to revise chart to get
required data elements
ED staff meetings:
• Describe the purpose of the registry
• Describe the needed data elements
• Ask staff for ideas of how best to collect
needed data elements (buy-in)
• Describe how data can/will be used— can
benefit them for presentations they do in
the community/hospital
ED staff meetings: continued
• Describe necessity of accurate data
collection for PI purposes
Examples:
Physician timeliness— ACS
requirement
.
(Our solution- team members
names on glass trauma doors)
TS Timeliness L1/L2
1st-2nd Q 2006
Not Documented
Documented
(n =93)
3%
97%
 Per review of nursing documentation only.
TS Timeliness L1/L2
1st-2nd Q 2006
>15 Mins
Within 15 Mins
(n = 90)
3%
97%
 Per review of nursing documentation only.
 3 cases > 15 mins.
PI examples for ED staff meeting cont.
Triss: Need ISS, RTS (systolic BP, RR,
GCS), Age, Blunt/Penetrating
Appropriateness of Activation: without
documentation of mechanism,
injuries, unable to determine
Appropriateness of Activations ALL
1st-2nd Q 2006
2%
(n=465)
20%
78%
Appropriate
Under Activated
Over Activated
Not Activated
ACS EXPECTED RATE
Under triage 5-10%
Over triage 30-50%
Appropriateness of Activations L1
1st-2nd Q 2006
(n=23)
9%
91%
Appropriate
Under Activated
Over Activated
Not Activated
Appropriateness of Activations L2
1st-2nd Q 2006
(n=75)
3%
97%
Appropriate
Under Activated
Over Activated
Not Activated
Appropriateness of Activations L3
1st-2nd Q 2006
(n=367)
25%
2%
73%
Appropriate
Under Activated
Over Activated
Not Activated
Data abstraction/entry
• Don’t guess-if the information isn’t documented, mark as
•
•
•
•
unknown
Check your abstraction form for missing data elements
and do your data entry before you return the chart to
medical records
Remember—garbage in, garbage out. Check your data
against other reports
Continue to update nurses on what’s missing from
documentation
Use your data: Report to ED, QI Dept, Physicians,
Administration, Others