Trauma Documentation and Trauma Triage

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Trauma DocumentationandTrauma Triage North
Country EMS ConferenceOctober 17, 2004
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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
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Objectives At the conclusion of this course, the
participant will be able to describe appropriate

• Trauma triage steps
• Trauma communication / report format
• Transport decision making

• Completion of the NH BEMS PCR
• General PCR guidelines
• SOAP format
• 17 Key Data Fields

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Why 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/traumapresentations.html
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Saf-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.
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Trauma System Goal

• To get the right patient
• to the right hospital
• at the right time.

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Trauma Statistics NH

• Leading cause of death in people age 1-34
• 1 MVCs
• 2 Firearms
• 3 Falls
• 5th leading cause of death overall
• 1/3 intentional
• 2/3 unintentional
• Someone in NH dies of trauma every 20 hours

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When Do Trauma Patients Die?
Severe Head or CV Injury
of Deaths
Major Torso or Head Injury
Infection and MSOF
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Organized Trauma Systems ? Death Disability
Through

• Injury Prevention
• System Planning
• Evaluation Monitoring
• Communication / Collaboration / Teamwork

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Trauma Systems Save Lives!
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NH Trauma System Development

• 1980s Exclusive Regional 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

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NH Trauma System Development

• 1995 Statewide Trauma Plan Finalized
• Senate Bill 122
• Trauma Coordinator position created
• Trauma Medical Review Committee named as the
  Oversight Committee
• Bureau of EMS named as the Lead Agency

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NH Trauma System Development

• 1999 Trauma Triage, Communications, and
  Transport Decision Making Educational Program
  offered
• 2002 TEMSIS Grant year 1
• 2004 Trauma Documentation and Trauma Triage
  Resource Guide Train-the-Trainer Program

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NH Trauma System Components

• Prevention Public Education
• Hospitals EMS Providers
• Medical Direction On-line Standing Orders
• Triage Transport Guidelines
• Rehabilitation
• Evaluation

What does that mean for me?
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Need to Know Information

• Hospital Assessment
• Trauma Triage Guidelines
• Communication Guidelines
• Transport Guidelines
• Resources available to you

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Hospital Assessment

• Performance Levels
• Initial, Advanced, or Leadership
• Roles
• Area or Regional
• Capability Levels
• Adult Pediatric Level I, II, or III

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Hospital Assessment

• Capability Levels
• Adult Pediatric Level I, II, or III

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Hospital AssessmentProcess

• Hospital Staff Self-Assessment
• Site Visit by Members of TMRC
• Confirmation
• Consultative / Assistance

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New Hampshire Trauma Facility Assignment
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Trauma Triage
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What is Trauma Triage?

• Patient Needs Hospital Resources
• Trauma patients are assessed and transported to
  the most appropriate hospital for that patients
  injuries.

MATCH
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Trauma Triage

• Goal Right Patient to the Right Hospital at the
  Right Time
• OVER Triage
• Minimally injured pts Trauma
  Centers
• Result Overburdens the system, no ill effect on
  pt care
• Not SO bad
• UNDER Triage
• Severely injured pts
  Non-Trauma Centers
• Result Hospitals may not be equipped to treat
  the pt and pt care may suffer
• Can be VERY BAD!

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Steps to ? Trauma Triage Accuracy

• Know the Trauma Triage and Transport Pathways
  Card
• Available through NH Department of Safety EMS-C
  program
• Be familiar with severity indicators (GCS RTS)
• Listen to your gut (sick v. not sick)
• Know your local resources
• On Scene Mutual Aid, ALS Intercept, Air
  Transport
• Hospital Local Hospital capabilities, distance
  to Regional Trauma Center

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• Front of Card
• Severity Indicators are based on
• Physiology
• Anatomy
• MOI Comorbid Factors

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Physiologic Indicators
Pediatric Adult
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Anatomic Indicators
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Contributing Factors
MOI Medical Conditions
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• Back of Card
• Scales Scores
• Trauma Communication

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Trauma Triage Steps To Recap

• Use Pathway Card to determine Pt Status
• Trauma Triage Communication
• Contact Medical Control
• Relay enough info to aid in decision making
• Transport Decision ? Transport

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Trauma Triage Examples
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Scenario 1
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Scene 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?
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Initial Assessment

• Airway is open and clear
• Opens eyes to loud verbal stimuli
• Localizes painful stimuli
• Confused verbal response to questions
• 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?
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Focused HP

• No obvious head injury, PERRLA
• No JVD or tracheal tugging, C-spine non-tender
• ? Chest expansion, crepitus, ? lung sounds R.
• Abdomen soft, but guarding 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.
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Trauma Communications

• What pertinent information will you
• communicate to medical control?

MIVT
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Transport Decision

• Injury Severity
• Hospital capability, location, driving time
• Area Level III Trauma Hospital is 10 minutes
• Regional Level II Hospital is 20 minutes
• ALS intercept is unavailable
• Helicopter is available and ETA to scene is 20
  minutes

What decision will Medical Control make? Why?
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Questions?
Additional scenarios are available to download on
the NH BEMS website.
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Trauma Communication "MIVT"
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Trauma Documentation
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"If it wasn't documented, it wasn't done."
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General PCR Guidelines

• Complete a PCR for every call and every pt
• This includes when care or transport was
• Requested
• Rendered
• Refused
• Cancelled

This includes pts treated by one agency and
transported by another. gt1 PCR may be generated
for the same pt/pt encounter.
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General PCR Guidelines

• A written PCR is
• Complete
• Accurate
• Legible
• Professional

• Be
• Objective
• Brief
• Accurate
• Clear

Legible Handwriting Correct Grammar and
Spelling are a must!
Poor documentation Poor care
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Changes to the PCR

• DO NOT use white out or any correction
  fluid/tape
• DO NOT try to obliterate or destroy information
• It gives the impression of trying to cover 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!

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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 numbered by the provider to
  correspond with the preprinted serial number on
  the PCR shall be submitted.
• 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

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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)
• The addendum shall be used to record details from
  the narrative section of the PCR form in the
  event that the form does not provide sufficient
  space

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What to Write in a PCR

• Who started care before you arrived
• How you found the patient
• Anything you found during your assessment
• Pertinent () and (-) findings
• Anything you did for the patient their response
• Where you left the patient ( with whom)
• Report given (to whom) questions answered
• Condition of the patient upon termination of care
• PIVs patent? MAEx4? ETT position verified?

If you did it, you should write it ( vice versa)
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"WNL"

• Within Normal Limits
• Or
• We Never Looked
• ???????

Be detailed!
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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

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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

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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)

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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

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Narrative Charting
"SOAP"
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Subjective

• 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

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Objective

• General Impression
• Primary Assessment
• ABCDE
• Secondary Assessment
• Head to Toe Exam

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Assessment

• Field Diagnosis
• What you believe the problem to be
• Working diagnosis
• Example Chest pain, R/O MI closed head
  injury with altered LOC pelvic fracture

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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 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.

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Narrative Charting
"CHART"
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CHART

• Chief Complaint
• History
• Assessment
• Rx
• Transport

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Specific PCR Instructions
17 Key Data Fields
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Demographics
3 Key Trauma Fields
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EMS Response Times
Key Trauma Field
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Vital Signs
4 Key Trauma Fields Pulse, SBP, DBP, RR
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Lung Sounds, Pupils, Skin, Temp
Key Trauma Field
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GCS 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
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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. GCS E3-V4-M411
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RTS
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 32 y/o female patient from the MVC
with GCS of E3-V4-M411 SBP of 92 RR of 12
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Data Collection
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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

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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

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Difficulties

• Garbage ingarbage out.
• Information collected must be complete and
  accurate or it will not be useful.

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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?

Being monitored currently
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Field 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?
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Approved Abbreviations

• A complete list is available in the accompanying
• Resource Guide

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Data Dictionary

• Clearly defines each data field and how to fill
  in the corresponding box on the PCR.
• Available through the State Office.

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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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Questions?Thank You.