Title: Trauma Documentation and Trauma Triage
1Trauma DocumentationandTriage Resource
GuideEducational Program 2004
2The 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
3Mission StatementTo 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.
4Outline
- Introduction/Overview
- History of Trauma System Development
- Trauma Triage
- Trauma Documentation
- Data Collection and Utilization
- Approved Abbreviations
- Data Dictionary
5Objectives At the conclusion of this course, the
participant will be able to describe
- 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
6Why is good documentation essential?
- If it was not documented, it was not done!
- Reflects adherance to the standard of care.
Resource Guide Power Point
Available for download at http//www.nh.gov/safet
y/ems/
7Saf-C 5902.07Recordkeeping and
ReportingRecordkeeping 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 methodsSaf-C
5902.08PCR Form Left SideDescribes how to
complete items on the left side of the PCR.Saf-C
5902.09PCR Form Right SideDescribes how to
complete items on the right side of the PCR.
8What is a Trauma System?
- An organized, coordinated effort in a defined
geographic region that delivers a full range of
care to all injured patients.
9Ideal Trauma System Components
- Injury Prevention
- EMS Field Intervention
- ED Care
- Surgical Interventions
- ICU Care
- Continued Hospital Care
- Rehabilitation
- Social Services
- Research QI
Requires teamwork and open communication from
all Prehospital - Hospital - NHBEMS
10Trauma System Goal
- To get the right patient
- to the right hospital
- at the right time.
11Trauma Statistics USA
- 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 gt40,000 fatalities per year
12Death from Trauma - USA
13Trauma Statistics NH
- 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
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15When Do Trauma Patients Die?
Severe Head or CV Injury
of Deaths
Major Torso or Head Injury
Infection and MSOF
16To Recap
Prevention Education of the Public,
Laws/Regulations
Golden Hour Appropriate Trauma Triage
Transport
Immediate
Appropriate Care Experienced, High-Quality
Resuscitation Continued Care
Early
Late
17Organized Trauma Systems Result in
- Reduced death disability through
- Injury Prevention
- System Planning
- Evaluation Monitoring
- Communication/Collaboration/ Teamwork
18Trauma Systems Save Lives!
19Trauma 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
20Trauma 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
21Trauma 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
22Trauma 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
23Trauma System Development NH
- 1999 Trauma Triage, Communications, and
Transport Decision Making Educational Program
offered - 2002 TEMSIS Grant
- 2004 Trauma Documentation and Triage Resource
Guide
24NH Trauma System Components
- Prevention Public Education
- Hospitals EMS Providers
- Medical Direction On-line Standing Orders
- Triage Transport Guidelines
- Rehabilitation
- Evaluation
25Need to Know Information
- Hospital Assessment
- Trauma Triage Guidelines
- Communication Guidelines
- Transport Guidelines
26Hospital Assessment
- Performance Levels
- Initial, Advanced, or Leadership
- Roles
- Area or Regional
27Hospital Assessment
- Capability Levels
- Adult Pediatric Level I, II, or III
28Hospital AssessmentProcess
- Hospital Staff Self-Assessment
- Site Visit by Members of TMRC
- Confirmation / Consultative
- Assistance
29New Hampshire Trauma Facility Assignment
30Trauma Triage
31What 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 patients
injuries.
32Trauma 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
33How do we perform Trauma Triage?
- Triage Transport Pathways Card
- Standardized Injury Severity Indicators
- GCS
- RTS
- Provider experience/judgment
34Steps 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
35- Front of Card
- Severity Indicators are based on
- Physiology
- Anatomy
- MOI Comorbid Factors
36Physiologic Indicators
Pediatric Adult
37Anatomic Indicators
38Contributing Factors
MOI Medical Conditions
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40Front of Card
- Back of Card
- Scales Scores
- Trauma Communication
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44RTS 0.9368 GCS 0.7326 SBP 0.2908 RR
Range 0 to 7.8408 Calculator available at
www.trauma.org Heavily weighted toward the GCS to
compensate for major head injury without
multisytem injury or major physiological
changes. EXAMPLE SBP 90 (coded value 4) 4 x
0.7326 2.93 RR 10 (coded value 4) 4 x
0.2908 1.16 GCS 13 (coded value 4) 4 x
0.9368 3.74 RTS 7.841
45RTS Survival
RTS 7.841 ? Ps 98.8
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48Trauma 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
49Trauma Triage Examples
50Trauma Triage Scenario 1
51Scenario 1
52Scene Info
- Motorcycle v. Pickup Truck
- Truck traveling 40 mph, ? Cycle speed
- 30 y/o male thrown 20 feet
- Truck has damage
- Riders helmet has few, minor scratches
What does this information provide us? What
additional information do you need?
53Initial Assessment
- Opens eyes to loud verbal stimuli
- Localizes painful stimuli
- Confused verbal response to questions
- Airway is open and clear
- RR32, ? chest expansion, R. wall bruising
- Strong radial pulses, no major bleeding
- Skin pale, moist, cool
Can you estimate GCS RTS? What is the Patient
Status?
54Focused HP
- 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
Confirm or dispute your initial severity
determination.
55Trauma Communications
- What pertinent information will you
- communicate to medical control?
56Transport 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
What decision will Medical Control make and why?
57Questions?
58Trauma Documentation
59"If it wasn't documented, it wasn't done."
60Uses for Documentation
- Medical continuity of care
- Administrative
- QI
- Assess needs (community agency)
- Billing Reimbursement
- Research
- Legal
61General PCR Guidelines
- Complete a PCR for every call and every pt
- This includes when care or transport was
- Requested
- Rendered
- Refused
- Cancelled
62General PCR Guidelines
- A written PCR is
- Complete
- Accurate
- Legible
- Professional
63General PCR Guidelines
- Legible handwriting
- Correct grammar and spelling
- Be
- Objective
- Brief
- Accurate
- Clear
64Changes 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!
65Addendums 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.
66Addendums 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)
67What 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? MAEx4? 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"WNL"
- Within Normal Limits
- Or
- We Never Looked
- ???????
69What 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
70Refusal 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
71Refusal 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)
72Refusal 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
73Narrative Charting
"SOAP"
74Subjective
- Any information you are able to elicit while
taking the patients history - Chief Complaint (CC)
- History of Present Illness (HPI)
- OPQRST AS/PN
- Past Medical Surgical History
- Meds and Allergies
75Objective
- General Impression
- Primary Assessment
- ABCDE
- Secondary Assessment
- Head to Toe Exam
76Assessment
- Field Diagnosis
- What you believe the problem to be
- Working diagnosis
- Example Chest pain, R/O MI
77Plan / 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 gt90/60. If no relief
from nitroglycerine, administer morphine 2 mg
SIVP, titrated to a maximum of 10 mg for
continued chest pain and BP gt90/60.
78Narrative Charting
"CHART"
79CHART
- Chief Complaint
- History
- Assessment
- Rx
- Transport
80Specific PCR Instructions
81Demographics
3 Key Trauma Fields
82CC HPI
83Past Medical History
84EMS Response Times
Key Trauma Field
85Vital Signs
4 Key Trauma Fields Pulse, SBP, DBP, RR
86Lung Sounds, Pupils, Skin, Temp
Key Trauma Field
87Narrative
88Ambulance Crew License Number, Signature
89First Responder Information
90Type of Ambulance Response
91Type of Call, MOI, Scene
92Care Given Patient
93Signs Symptoms by Site
94Signs Symptoms by Type
95GCS RTS
4 Key Trauma Fields GCS Eye GCS Verbal GCS
Motor GCS Total
4 Key Trauma Fields RTS GCS RTS BP RTS RR RTS
Total
96GCS Eye
Exam Descriptor Patients Response Assigned GCS Score
Eye Opening Response Spontaneous Opens eyes spontaneously requires no prompting (verbal or painful stimulus) to do so 4
Eye Opening Response To Voice Opens eyes when asked to in a loud voice (to name of command) 3
Eye Opening Response To Pain Opens eyes in response to a painful stimuli, such as a pinch or nail bed pressure 2
Eye Opening Response None Does not open eyes 1
97GCS Verbal
Exam Descriptor Patients Response Assigned GCS Score
Best Verbal Response Oriented Patient is awake, alert, and oriented. Able to carry on a conversation. 5
Best Verbal Response Confused Patient can speak and formulate words, but seems confused or disoriented. Example patient who keeps asking what happened? 4
Best Verbal Response Inappropriate Words Patient can formulate words, but they are out of context to the situation or make no sense. Example patient answers yes to everything. 3
Best Verbal Response Incomprehensible Sounds Patient makes sounds, but can not formulate words. Examples moans, high-pitched yelling. 2
Best Verbal Response None No verbal response or noise. 1
98GCS Motor
Exam Descriptor Patients Response Assigned GCS Score
Best Motor Response Obeys Commands Follows simple commands, such as squeeze my fingers. 6
Best Motor Response Localizes Pain Pulls or pushes rescuers hand away when rescuer delivers a painful stimulus (pinch or nail bed pressure). 5
Best Motor Response Withdraws (pain) Pulls a part of body away when rescuer delivers a painful stimulus (pinch or nail bed pressure). 4
Best Motor Response Flexion (pain) Flexes body inappropriately to pain. 3
Best Motor Response Extension (pain) Body becomes rigid and extended to pain. 2
Best Motor Response None No motor response to pain. 1
99 Exam Descriptor Assigned GCS Score
Eye Opening Response Spontaneous 4
Eye Opening Response To Voice 3
Eye Opening Response To Pain 2
Eye Opening Response None 1
Best Verbal Response Oriented 5
Best Verbal Response Confused 4
Best Verbal Response Inappropriate Words 3
Best Verbal Response Incomprehensible Sounds 2
Best Verbal Response None 1
Best Motor Response Obeys Commands 6
Best Motor Response Localizes Pain 5
Best Motor Response Withdraws (pain) 4
Best Motor Response Flexion (pain) 3
Best Motor Response Extension (pain) 2
Best Motor Response None 1
Total GCS 11
GCS
32 y/o female patient from a MVC with an ALOC.
She opens her eyes to loud voice command, keeps
asking What happened?, and withdraws her arm
when the EMT-P starts the IV
100RTS
Parameter Value Assigned RTS Score
Glascow Coma Scale (GCS) Total points 13-15 4
Glascow Coma Scale (GCS) Total points 9-12 3
Glascow Coma Scale (GCS) Total points 6-8 2
Glascow Coma Scale (GCS) Total points 4-5 1
Glascow Coma Scale (GCS) Total points 3 0
Systolic Blood Pressure (SBP) gt89 mm Hg 4
Systolic Blood Pressure (SBP) 76-89 mm Hg 3
Systolic Blood Pressure (SBP) 50-75 mm Hg 2
Systolic Blood Pressure (SBP) 1-49 mm Hg 1
Systolic Blood Pressure (SBP) No Pulse 0
Respiratory Rate (RR) 10-29/min 4
Respiratory Rate (RR) gt29/min 3
Respiratory Rate (RR) 6-9/min 2
Respiratory Rate (RR) 1-5/min 1
Respiratory Rate (RR) None 0
Total RTS ________________ Total RTS ________________ Total RTS ________________
101RTS
Parameter Value Assigned RTS Score
Glascow Coma Scale (GCS) Total points 13-15 4
Glascow Coma Scale (GCS) Total points 9-12 3
Glascow Coma Scale (GCS) Total points 6-8 2
Glascow Coma Scale (GCS) Total points 4-5 1
Glascow Coma Scale (GCS) Total points 3 0
Systolic Blood Pressure (SBP) gt89 mm Hg 4
Systolic Blood Pressure (SBP) 76-89 mm Hg 3
Systolic Blood Pressure (SBP) 50-75 mm Hg 2
Systolic Blood Pressure (SBP) 1-49 mm Hg 1
Systolic Blood Pressure (SBP) No Pulse 0
Respiratory Rate (RR) 10-29/min 4
Respiratory Rate (RR) gt29/min 3
Respiratory Rate (RR) 6-9/min 2
Respiratory Rate (RR) 1-5/min 1
Respiratory Rate (RR) None 0
Total RTS ____11__________ Total RTS ____11__________ Total RTS ____11__________
Example The patient from the MVC above with a
GCS 3-4-411 SBP of 92 RR of 12
102Billing Information
103Mileage
104Hospital Linkage Data
105Refusal of Care
106Data Collection
107PCR Routing
- Top Copy
- EMS Unit
- 2nd Copy
- Receiving Hospital
- 3rd Copy
- NHBEMS
- 4th Copy
- Agencys Hospital EMS Coordinator
108NHBEMS 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
Enter TEMSIS...
109TEMSIS
- Real time Data Collection Analysis
- Comprehensive statewide system
- Will support QA and CQI
110Why 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
111Examples of Reports
- Response time
- Performance, such as ETI success rates
- Procedures, such as number of IVs per provider
per year - Number of CPR calls
112Difficulties
- Garbage ingarbage out.
- Information collected must be complete and
accurate or it will not be useful.
11317 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?
Being monitored currently
114Field Name of Total Trauma Calls Reported
On Scene Time 92.8
Patient Status 73.9
Pulse 72.4
Respiratory Rate 66.4
Systolic BP 66.1
GCS Total 59.1
GCS Eye 59.0
GCS Motor 59.0
GCS Verbal 59.0
Diastolic BP 56.0
RTS Total 49.7
RTS GCS 49.5
RTS Respiratory Rate 49.1
RTS BP 49.1
Trauma Patient? 4.4
Temperature 0.0
Trauma Team Activated? 0.0
How are we doing?
115Approved Abbreviations
- A complete list is available in the accompanying
- Resource Guide
116Data Dictionary
- Clearly defines each data field and how to fill
in the corresponding box on the PCR. - Available through the State Office.
117Summary
- 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.
118Questions?Thank You.