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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

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Trauma Registry: The Nuts & Bolts of Data Collection

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  1. Trauma Registry: The Nuts & Bolts of Data Collection Karla Bryan, RN, BSN Trauma Coordinator EIRMC

  2. 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)

  3. 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

  4. 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.

  5. 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

  6. 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

  7. 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)

  8. TS Timeliness L1/L21st-2nd Q 2006 (n =93) • Per review of nursing documentation only.

  9. TS Timeliness L1/L21st-2nd Q 2006 (n = 90) • Per review of nursing documentation only. • 3 cases > 15 mins.

  10. 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

  11. Appropriateness of Activations ALL1st-2nd Q 2006 (n=465) ACS EXPECTED RATE Under triage 5-10% Over triage 30-50%

  12. Appropriateness of Activations L11st-2nd Q 2006 (n=23)

  13. Appropriateness of Activations L21st-2nd Q 2006 (n=75)

  14. Appropriateness of Activations L31st-2nd Q 2006 (n=367)

  15. 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

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