Emergency Department Trauma Flowsheet Documentation Evelyn ClarkKula RN

Emergency Department Trauma Flowsheet Documentation Evelyn Clark-Kula, RN, BSN, Janice Gillespie, RN, Bridget Gaughan, RN, MSN, Sylvia Wright, RN, MSN, Kristi Dombrow, RN, BSN, and Karen Steed, RN, BSN Confidential: For Quality Improvement Purposes Only

Project Aim Statement • The Trauma QI Committee identified that certain key indicators were not consistently being documented on the trauma flowsheets. The aim of this project was to increase compliance by the Emergency Department nurses in documenting these indicators. Confidential: For Quality Improvement Purposes Only

Measurement Goal • All indicators >80% compliance per ACS (American College of Surgeons) criteria by February 1, 2008 Confidential: For Quality Improvement Purposes Only

Solutions Implemented • Monthly Trauma QI attendance at ED Clinical Operations Committee Meetings • Letters written to ED RNs who did not meet documentation indicators beginning 8/1/07 • Distribution of letters to ED Staff by ED Management Team • Education of ED staff by ED Educator and ED Management Team • Informal real-time chart review amongst fellow ED RNs and Management Team • Trauma Program Manager review of real-time trauma resuscitation documentation • Posting of flowsheet indicators on bedside tables in ED Trauma Bay Confidential: For Quality Improvement Purposes Only

Sample ED RN Letter Confidential-Quality Improvement Material Loyola University Medical Center Trauma Services Emergency Department RN Documentation MR# 0000000 Smith, John To: Debbie Reynolds, RN From: Jan Gillespie, RN Trauma Program Manager Trauma QI Committee Debbie, on 8/1/07 you helped care for the above mentioned patient. On the trauma flowsheet you documented when the Trauma Attending was called and when they answered, but not if they arrived or the time of their arrival – you left that space blank. If they do not arrive in the trauma bay a (-) should be placed in the arrival box – otherwise a time must be written when they arrive. To chart that the trauma team was present is not sufficient. In addition, the patient’s Intake & Output were not documented at the time of disposition. This is for educational purposes and trending. If you have any questions please call me at x 73715, page me at 15768, or email me. On a positive note, you did chart the pt time of arrival in the box correctly, and the patient’s temperature. Attached please find a copy of the above mentioned flowsheet. Confidential: For Quality Improvement Purposes Only

Results • All indicators reached >80% goal in February of 2008 as reported at ED Clinical Operations Committee Meeting Confidential: For Quality Improvement Purposes Only

Confidential: For Quality Improvement Purposes Only Month ch 8 20 08 ry ua ar M Fe br y ar nu Ja 7 00 7 r 2 be ec em D be r 2 00 00 7 r 2 be ct o em ov N O 7 40 00 7 em be r 2 Se pt 00 20 07 07 20 t 2 us ug A ly Ju ne 07 20 Percent of charts with documentation of trauma attending arrival 80 Ju ay M 100 Documentation of Trauma Attending Arrival 90 Mean = 77. 55 70 Letters to staff initiated 60 50

Percentage of flowsheets with patient arrival time documented em be r 2 O ct ob 006 er N ov 20 em 06 be D ec r em 200 6 be r Ja nu 200 6 a Fe ry 20 br 07 ua ry 20 M 07 ar ch 20 07 A pr il 20 07 M ay 20 07 Ju ne 20 07 Ju ly 2 A ug 007 us Se t 2 pt em 00 be 7 r 2 O ct ob 007 N er ov em 20 be 07 D r 2 ec em 00 be 7 r Ja nu 200 7 a Fe ry 20 br 08 ua ry 20 M 08 ar ch 20 08 Se pt 104 98 Documentation of Patient Arrival Time 102 100 Letters to staff initiated Mean = 96. 47 96 94 92 90 Confidential: For Quality Improvement Purposes Only Month

ly 20 06 Percentage of flowsheets with IV fluid volumes documented 60 us Se t pt em 200 be 6 O ct r 20 ob 06 N ov er 2 em 00 6 b D ec er em 20 be 06 r Ja nu 200 6 a Fe ry 2 br ua 007 ry 20 M ar 07 ch 20 A pr 07 il 20 M 07 ay 2 Ju 007 ne 2 Ju 007 ly 2 A ug 00 us 7 Se t pt em 200 be 7 O ct r 20 o 07 N ov ber em 20 be 07 D r 2 ec em 00 be 7 Ja r nu 20 07 a Fe ry 2 br ua 008 ry M 20 ar ch 08 20 08 ug A Ju Documentation of IV Fluid Volume Infused 90 80 Letters to staff initiated 70 Mean = 60. 00 50 40 30 Confidential: For Quality Improvement Purposes Only Month

10 us Se t pt em 200 be 6 O r 2 ct ob 006 N ov er 2 00 em 6 b D ec er em 20 be 06 r Ja nu 200 6 a Fe ry 20 br 07 ua ry 20 M ar 07 ch 20 A pr 07 il 20 07 M ay 2 Ju 007 ne 20 07 Ju ly 2 A ug 007 us Se t pt em 200 be 7 O r 2 ct 0 o be 07 N ov r em 20 be 07 D r 2 ec em 00 be 7 r Ja nu 200 7 a Fe ry 20 br 08 ua ry 20 M ar 08 ch 20 08 ug A Percent of Flowsheets with Output Documented 100 Documentation of Output on Trauma Flowsheet 90 80 70 Confidential: For Quality Improvement Purposes Only Letters to staff initiated 60 Mean = 58. 45 50 40 30 20 Month

n Fe uar br y 2 ua 0 0 M ry 6 ar 20 ch 0 6 A 20 pr 0 il 6 M 20 ay 06 Ju 20 ne 06 Ju 20 0 A ly 2 6 Se ugu 00 pt st 6 em 2 O be 006 c r N tob 20 ov e 0 6 e r D mb 200 ec e em r 2 6 Ja be 006 n r Fe uar 200 br y 2 6 ua 0 0 M ry 7 ar 20 ch 0 7 A 20 pr 0 il 7 M 20 ay 07 Ju 20 ne 07 Ju 20 0 A ly 2 7 u Se gu 00 pt st 7 em 2 0 O be 07 c N to r 2 ov b 0 em er 07 2 D ec ber 007 em 2 0 Ja be 07 n r Fe uar 200 br y 7 ua 20 0 M ry 8 ar 20 ch 0 8 20 08 Ja Percent of charts with temperature documented Documentation of Temperature on Trauma Flowsheet 105 100 Mean = 93. 22 95 90 Confidential: For Quality Improvement Purposes Only Letters to staff initiated 85 80 Month

Analysis • Improved documentation of Trauma Attending Arrival, Patient Arrival, Temperature, and Intake/Output to greater than >80% goal • Greatest improvement was noticed after letters were sent to ED RNs Confidential: For Quality Improvement Purposes Only

Next Steps • Education of ED staff will remain continuous due to turnover of staff credentialed to care for trauma patients • In past years, decreased emphasis on documentation has resulted in poor compliance with specific indicators Confidential: For Quality Improvement Purposes Only