Trauma Trauma DocumentationDocumentationandandTrauma Triage Trauma Triage

North Country North Country EMS ConferenceEMS ConferenceOctober 17, 2004October 17, 2004

The planning of the TEMSIS Project and The planning of the TEMSIS Project and Trauma Documentation & Trauma Triage Trauma Documentation & Trauma Triage Educational Programs are funded in part Educational Programs are funded in part

by the United States Department of by the United States Department of Health and Human Services, Health Health and Human Services, Health

Resources and Services Administration – Resources and Services Administration –

Trauma-EMS Grant Program.Trauma-EMS Grant Program.HRSA – H81MC00025-02-04HRSA – H81MC00025-02-04

Objectives Objectives At the conclusion of this course, the participant At the conclusion of this course, the participant

will be able to describe appropriate: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

Why is good documentation Why is good documentation essential?essential?

Resource Guide & Power Point:Resource Guide & Power Point:Available for download at:

http://www.nh.gov/safety/ems/traumapresentations.html

If it was not documented, it was not done!If it was not documented, it was not done!

Reflects adherance to the standard of care.Reflects adherance to the standard of care.

Saf-C 5902.07Saf-C 5902.07Recordkeeping and ReportingRecordkeeping and Reporting

“Recordkeeping 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 methods

Saf-C 5902.08Saf-C 5902.08PCR Form – Left SidePCR Form – Left Side

Describes how to complete items on the left side of the PCR.

Saf-C 5902.09Saf-C 5902.09PCR Form – Right SidePCR Form – Right Side

Describes how to complete items on the right side of the PCR.

Trauma System GoalTrauma System Goal

To get the right patient To get the right patient

to the right hospital to the right hospital

at the right time.at the right time.

■ 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

Trauma Statistics – NHTrauma Statistics – NH

When Do Trauma Patients Die?When Do Trauma Patients Die?

05

101520253035404550

Immediate Early Late

% of Deaths

Severe Head or CV Injury

Major Torso or Head Injury

Infection and MSOF

Organized Trauma Systems Organized Trauma Systems Death & Disability Through: Death & Disability Through:

■ Injury Prevention

■ System Planning

■ Evaluation & Monitoring

■ Communication / Collaboration / Teamwork

NH Trauma System DevelopmentNH 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

NH Trauma System Development 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

NH Trauma System Development 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

NH Trauma System ComponentsNH Trauma System Components■ Prevention & Public Education

■ Hospitals & EMS Providers■ Medical Direction: On-line & Standing Orders■ Triage & Transport Guidelines■ Rehabilitation■ Evaluation

““Need to Know” InformationNeed to Know” Information

■ Hospital Assessment

■ Trauma Triage Guidelines

■ Communication Guidelines

■ Transport Guidelines

■ Resources available to you

Hospital AssessmentHospital Assessment

■ Performance Levels■Initial, Advanced, or Leadership

■ Roles■Area or Regional

■ Capability Levels■Adult & Pediatric; Level I, II, or III

Hospital Assessment:Hospital Assessment:ProcessProcess

■ Hospital Staff Self-Assessment

■ Site Visit by Members of TMRC■Confirmation

■Consultative / Assistance

New Hampshire Trauma Facility Assignment

What is Trauma Triage?What is Trauma Triage?

Patient NeedsPatient Needs Hospital Hospital ResourcesResources

Trauma patients are assessed and transported to Trauma patients are assessed and transported to the most appropriate hospital for that patient’s the most appropriate hospital for that patient’s

injuries.injuries.

MATCH

Trauma TriageTrauma 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!

Steps to Steps to Trauma Triage Accuracy 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

Front of Card

Severity Indicators are based on:

•Physiology

•Anatomy

•MOI & Comorbid Factors

Back of Card

•Scales & Scores

•Trauma Communication

Trauma Triage Steps: To RecapTrauma 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

Scenario 1Scenario 1

Scene InfoScene Info

Motorcycle v. Pickup Truck Truck traveling 40 mph, ? Cycle speed 30 y/o male thrown 20 feet Truck has damage Rider’s helmet has few, minor scratches

What does this information provide us?

What additional information do you need?

Initial AssessmentInitial Assessment Airway is open and clear Opens eyes to loud verbal stimuli Localizes painful stimuli Confused verbal response to questions RR=32, ≠ 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?

Focused H&PFocused H&P 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.

Trauma CommunicationsTrauma Communications

What pertinent information will you

communicate to medical control?

“MIVT”

Transport DecisionTransport 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?

Questions?Questions?

Additional scenarios are available to download on the NH BEMS website.

General PCR GuidelinesGeneral 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. >1 PCR may be generated for the same pt/pt encounter.

General PCR GuidelinesGeneral 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”

Changes to the PCRChanges 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!

Addendums to the PCRAddendums 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

Addendums to the PCRAddendums 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

What to Write in a PCRWhat 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? MAE=x4? ETT position verified?

If you did it, you should write it (& vice versa)

““Within Normal Limits”Within Normal Limits”OrOr

““We Never Looked”We Never Looked”??????????????

What What NOTNOT to Write in a PCR 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

Refusal DocumentationRefusal 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

Refusal DocumentationRefusal 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)

Refusal ProcedureRefusal 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

Narrative ChartingNarrative Charting

SubjectiveSubjective

■ Any information you are able to elicit while taking the patient’s history:■ Chief Complaint (CC)■ History of Present Illness (HPI)

■ “OPQRST – AS/PN”

■ Past Medical & Surgical History■ Meds and Allergies

ObjectiveObjective

■ General Impression

■ Primary Assessment■ ABCDE

■ Secondary Assessment■ Head to Toe Exam

AssessmentAssessment

■ 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”

Plan / ManagementPlan / 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 >90/60. If no relief from nitroglycerine, administer morphine 2 mg SIVP, titrated to a maximum of 10 mg for continued chest pain and BP >90/60.”

Narrative ChartingNarrative Charting

CHARTCHART

■ Chief Complaint

■ History

■ Assessment

■ Rx

■ Transport

DemographicsDemographics

33 Key Trauma FieldsKey Trauma Fields

EMS Response TimesEMS Response Times

Key Trauma FieldKey Trauma Field

Vital SignsVital Signs

4 Key Trauma Fields:4 Key Trauma Fields:

Pulse, SBP, DBP, RRPulse, SBP, DBP, RR

Lung Sounds, Pupils, Skin, Lung Sounds, Pupils, Skin, TempTemp

Key Trauma FieldKey Trauma Field

GCS & RTSGCS & RTS4 Key 4 Key Trauma Trauma Fields:Fields:

GCS EyeGCS Eye

GCS VerbalGCS Verbal

GCS MotorGCS Motor

GCS TotalGCS Total

4 Key 4 Key Trauma Trauma Fields:Fields:

RTS GCSRTS GCS

RTS BPRTS BP

RTS RRRTS RR

RTS TotalRTS Total

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-M4=11

ExamDescriptor Assigned

GCS Score

Eye Opening Response

Spontaneous 4

To Voice 3

To Pain 2

None 1

Best Verbal Response

Oriented 5

Confused 4

Inappropriate Words 3

Incomprehensible Sounds

2

None 1

Best Motor Response

Obeys Commands 6

Localizes Pain 5

Withdraws (pain) 4

Flexion (pain) 3

Extension (pain) 2

None 1

Total GCS 11

Parameter Value Assigned RTS Score

Glascow Coma Scale (GCS) Total points

13-15 4

9-12 3

6-8 2

4-5 1

3 0

Systolic Blood Pressure (SBP) >89 mm Hg 4

76-89 mm Hg 3

50-75 mm Hg 2

1-49 mm Hg 1

No Pulse 0

Respiratory Rate (RR) 10-29/min 4

>29/min 3

6-9/min 2

1-5/min 1

None 0

Total RTS: ____11__________

Example:The 32 y/o female patient from the MVC with:

GCS of E3-V4-M4=11

SBP of 92

RR of 12

Why do we collect data?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

Examples of ReportsExamples of Reports

■ Response time

■ Performance, such as ETI success rates

■ Procedures, such as number of IVs per provider per year

■ Number of CPR calls

Difficulties…Difficulties…

“Garbage in…garbage out.”

Information collected must be complete and accurate or it will not be useful.

17 Key Trauma Data Fields17 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?

Field NameField Name % of Total Trauma Calls % of Total Trauma Calls ReportedReported

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

Approved AbbreviationsApproved Abbreviations

A complete list is available in the accompanying

Resource Guide

Data DictionaryData Dictionary

Clearly defines each data field and how to fill in the

corresponding “box” on the PCR.

Available through the State Office.

SummarySummary

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.

Questions?Questions?

Thank You.Thank You.