“Where Are My Vitals?” Implementing Electronic Trauma Documentation

Abstract

Session F presented Friday, September 28, 11:30 am-12:30 pm Purpose: Trauma documentation on a paper flow sheet had continued one year after the institution’s large scale EHR go live. Multiple regulatory bodies’ audits found inconsistencies due to the dual documentation processes. Implementation of electronic trauma documentation record was noted as a safety priority. Design: This quality improvement project began with a SWOT analysis for facilitators and barriers. A mixed methodology of PDSA and lean six-sigma QI processes were utilized to guide the project. Setting: The setting is a moderate size ED as part of a tertiary care academic medical center. The hospital is located in the mid-Atlantic region within an urban setting. The hospital has 438 licensed inpatient beds with 14 different Centers of Excellence. The institution is a Level II trauma center, the regional burn center, and a certified Comprehensive Stroke Center. The ED is a 40 bed unit that serves on average 164 patients per day reaching almost 60,000 patients per year. As a Level II trauma center, close to 3000 trauma patients are seen a year. Approximately, one-third are considered in need of activating a full trauma team for immediate life-saving interventions. The remaining two-third require interventions managed by ED personnel. Initial trauma resuscitation for both categories is preformed in a trauma resuscitation treatment area. Care is then continued throughout the ED, OR or ICU settings. Participants/Subjects: A project team consisted of selected frontline nursing staff, nursing informatics and lead by the ED CNS. All ED and Critical Care float pool staff participated in the implementation and education. Methods: Highlights are noted as the use of multiple shadow and parallel charting reviews to revise the initial electronic trauma tool for usability and mimic current workflow. Expectations of standard work along with a written ED Trauma Documentation Operations and Performance plan was provided during a mandatory education session. All safety issues and concerns were prioritized for patient safety and throughput. Directly impacted inpatient stakeholders were made aware of the Go-Live date and given access to the new format. Results/Outcomes: One year prior to implementation, approximately, four safety event reports per month were entered for poor or inconsistency trauma documentation. None have been noted in the five months since implementation. During and post implementation, daily audits of all trauma records were conducted by frontline staff and repeated by ED nursing leadership for state mandated compliance elements. Pre-implementation data compliance elements was unavailable. Prior antedoctal data noted poor compliance with the institution’s trauma vital sign, and neurological status policies. Post-implementation documentation compliance for the thirteen state mandated data elements average 89 % compliance. Six elements are noted above the 90% threshold, five elements ranging from 83 to 89% with only one element as an outlier at 72%. Implications: Inter-professional collaboration between the ED CNS, nursing informatics and ED frontline staff are noted to be vital in the success of the project. Improved communication, along with staff engagement has also been noted to be influential in success. Communication to all key stakeholders was paramount. The written plan reinforced ED Leadership’s commitment to safe, quality care.