Trauma Documentation and Trauma Triage North Country EMS Conference October 17, 2004

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. 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 Objectives At the conclusion of this course, the participant will be able to describe appropriate:

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/safety/ems/traumapresentations.html

5. Saf-C 5902.07Recordkeeping 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 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

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

19. New Hampshire Trauma Facility Assignment

20. Trauma Triage

21. Patient Needs Hospital Resources Trauma patients are assessed and transported to the most appropriate hospital for that patient’s injuries. What is Trauma Triage? MATCH

22. 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!

23. 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

24. Front of Card • Severity Indicators are based on: • Physiology • Anatomy • MOI & Comorbid Factors

26. Physiologic Indicators Pediatric & Adult

27. Anatomic Indicators

28. Contributing Factors MOI & Medical Conditions

29. Back of Card • Scales & Scores • Trauma Communication

35. 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

36. Trauma Triage Examples

37. Scenario 1

38. Scene 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?

39. Initial 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?

40. Focused 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.

41. Trauma Communications What pertinent information will you communicate to medical control? “MIVT”

42. 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?

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

44. Trauma Communication "MIVT"

45. Trauma Documentation

46. "If it wasn't documented, it wasn't done."

47. 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. >1 PCR may be generated for the same pt/pt encounter.

48. A written PCR is: Complete Accurate Legible Professional Be: Objective Brief Accurate Clear General PCR Guidelines Legible Handwriting & Correct Grammar and Spelling are a must! “Poor documentation = Poor care”

49. 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!

50. 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