Trauma Documentation and Trauma Triage - PowerPoint PPT Presentation

About This Presentation
Title:

Trauma Documentation and Trauma Triage

Description:

The goal of prehospital care of trauma patients is ... Standardized patient care practice and rapid access to advanced life support; Standardized trauma triage ... – PowerPoint PPT presentation

Number of Views:1107
Avg rating:3.0/5.0
Slides: 83
Provided by: NHDeprtme8
Learn more at: https://www.nh.gov
Category:

less

Transcript and Presenter's Notes

Title: Trauma Documentation and Trauma Triage


1
Trauma DocumentationandTrauma Triage North
Country EMS ConferenceOctober 17, 2004
2
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
3
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

4
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
5
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.
6
Trauma System Goal
  • To get the right patient
  • to the right hospital
  • at the right time.

7
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

8
(No Transcript)
9
When Do Trauma Patients Die?
Severe Head or CV Injury
of Deaths
Major Torso or Head Injury
Infection and MSOF
10
Organized Trauma Systems ? Death Disability
Through
  • Injury Prevention
  • System Planning
  • Evaluation Monitoring
  • Communication / Collaboration / Teamwork

11
Trauma Systems Save Lives!
12
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

13
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

14
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

15
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?
16
Need to Know Information
  • Hospital Assessment
  • Trauma Triage Guidelines
  • Communication Guidelines
  • Transport Guidelines
  • Resources available to you

17
Hospital Assessment
  • Performance Levels
  • Initial, Advanced, or Leadership
  • Roles
  • Area or Regional
  • Capability Levels
  • Adult Pediatric Level I, II, or III

18
Hospital Assessment
  • Capability Levels
  • Adult Pediatric Level I, II, or III

19
Hospital AssessmentProcess
  • Hospital Staff Self-Assessment
  • Site Visit by Members of TMRC
  • Confirmation
  • Consultative / Assistance

20
New Hampshire Trauma Facility Assignment
21
Trauma Triage
22
What is Trauma Triage?
  • Patient Needs Hospital Resources
  • Trauma patients are assessed and transported to
    the most appropriate hospital for that patients
    injuries.

MATCH
23
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!

24
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

25
  • Front of Card
  • Severity Indicators are based on
  • Physiology
  • Anatomy
  • MOI Comorbid Factors

26
(No Transcript)
27
Physiologic Indicators
Pediatric Adult
28
Anatomic Indicators
29
Contributing Factors
MOI Medical Conditions
30
  • Back of Card
  • Scales Scores
  • Trauma Communication

31
(No Transcript)
32
(No Transcript)
33
(No Transcript)
34
(No Transcript)
35
(No Transcript)
36
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

37
Trauma Triage Examples
38
Scenario 1
39
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?
40
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?
41
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.
42
Trauma Communications
  • What pertinent information will you
  • communicate to medical control?

MIVT
43
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?
44
Questions?
Additional scenarios are available to download on
the NH BEMS website.
45
Trauma Communication "MIVT"
46
Trauma Documentation
47
"If it wasn't documented, it wasn't done."
48
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.
49
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
50
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!

51
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

52
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

53
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)
54
"WNL"
  • Within Normal Limits
  • Or
  • We Never Looked
  • ???????

Be detailed!
55
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

56
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

57
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)

58
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

59
Narrative Charting
"SOAP"
60
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

61
Objective
  • General Impression
  • Primary Assessment
  • ABCDE
  • Secondary Assessment
  • Head to Toe Exam

62
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

63
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.

64
Narrative Charting
"CHART"
65
CHART
  • Chief Complaint
  • History
  • Assessment
  • Rx
  • Transport

66
Specific PCR Instructions
17 Key Data Fields
67
Demographics
3 Key Trauma Fields
68
EMS Response Times
Key Trauma Field
69
Vital Signs
4 Key Trauma Fields Pulse, SBP, DBP, RR
70
Lung Sounds, Pupils, Skin, Temp
Key Trauma Field
71
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
72
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
73
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
74
Data Collection
75
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

76
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

77
Difficulties
  • Garbage ingarbage out.
  • Information collected must be complete and
    accurate or it will not be useful.

78
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
79
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?
80
Approved Abbreviations
  • A complete list is available in the accompanying
  • Resource Guide

81
Data Dictionary
  • Clearly defines each data field and how to fill
    in the corresponding box on the PCR.
  • Available through the State Office.

82
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.

83
Questions?Thank You.
Write a Comment
User Comments (0)
About PowerShow.com