Burnie, J., Heist, C., Hardin, E., Donoghue, K., Dunigan, K., & Sheets, K. (July, 2018). Successful Implementation of Electronic Trauma Documentation in a Level III Trauma Center- It Can Be Done! Online Journal of Nursing Informatics (OJNI), 22(2), Available at http://www.himss.org/ojni
An interdisciplinary team developed and implemented an electronic process to document care provided to patients who have sustained traumatic injuries. The goal of the team was to integrate the paper Emergency Department (ED) trauma flow sheet into the electronic health record (EHR) ensuring timely access by all system users to trauma documentation and enabling improved data abstraction and quality of trauma documentation. A willingness to spend the time on the ground work and develop a hands-on, case-based educational approach resulted in a positive outcome that improved trauma documentation, enhanced data extraction capability, and allowed all end users to visualize care in the ED.
The introduction of a trauma narrator into an organization’s electronic health record (EHR) was a 12-month journey of collaborative inter-professional work. A trauma narrator is an Epic (Epic Systems Corporation, Verona, Wisconsin) software tool that allows Emergency Department (ED) nurses to follow a step-by-step process to electronically document care provided to patients who have sustained traumatic injuries. A team of ED trauma staff nurses, a trauma program manager, an ED clinical nurse specialist, informatics specialists with ED experience, registration team members, trauma registrars, and trauma physicians worked diligently to develop a trauma EHR in a level-III trauma center in a suburb of Cincinnati. The trauma center staff provided care for 434 trauma patients in 2016. During this time, trauma documentation was performed entirely on paper. Advances in the EHR and a desire to improve documentation brought the team together to begin working on transitioning documentation from a paper process to an electronic one.
A literature search resulted in limited evidence published on electronic documentation of trauma care. The team used the lessons learned from the three groups that published their experiences of the transition to electronic documentation for trauma patients, including ensuring that skilled trauma nurses work collaboratively with the trauma program leader to develop an EHR based on the current paper forms, assuring adequate computer access for staff, incorporating automatic download of vital signs, and developing adequate training for users (Bilyeu & Estes, 2013; Coffey et al., 2015; D’Huyvetter, Lang, Heimer, & Cogbill, 2014). Coffey and colleagues (2015) compared charts from trauma care provided in their level-1 pediatric trauma center. They compared 200 paper documented cases and 200 electronically documented cases and found fewer missing documentation points in cases that used electronic documentation. They advocated for adoption of electronic documentation for all trauma care. Bilyea and Estes (2013) reported a similar finding after examining 100 charts before implementation of electronic documentation and 100 charts after implementation. They reported a 7% improvement in completion of charting when electronic processes were used. Finally, D’Huyvetter and colleagues (2014) studied 603 trauma cases and found that compared to paper documentation, documenting electronically resulted in an improvement in documentation completion, allowed for generation of reports for internal projects, and supported their trauma center reverification site visit.
The goal of the team was to integrate the hospital’s current paper ED trauma flow sheet into the EHR, ensuring timely access by all system users to trauma documentation and enabling improved data abstraction and quality of trauma documentation.
The first step in making the transition to electronic documentation was to ensure that accurate data abstraction was a priority (D’Huyvetter et al., 2014). This required that the team identified key stakeholders in the process change. Registration staff was identified as crucial stakeholders because of the importance of an accurate time stamp for trauma activations. Additionally, specific registration-related information is required when hospital systems seek trauma center verification by the American College of Surgeons (ACS). Therefore, the team collaborated early in the planning process with the trauma registrar to identify the key information that is required for trauma center verification, including trauma activation time, classification, surgeon arrival time, Glasgow Coma Scale score, and vital signs. In addition to the registrar, the team recognized that a successful transition to electronic documentation of trauma care would require an experiential educational approach that was user-friendly. Therefore, the team engaged end users early in the process to gather feedback from clinical staff about the current documentation processes to ensure success of the project. These trauma nurse end-users were present at each meeting during the software development process to ensure real life processes were captured.
To be prepared for accreditation by the ACS, a strategic timeline was developed. One requirement of the ACS accreditation is that the trauma program manager needs to provide hard copies of the trauma documentation for surgeon review. For this reason, team members planned the “go-live” date to allow for an entire year of electronic documentation before the next ACS trauma verification visit. The team determined that trauma nurses must have time to become familiar with the changes to documentation. Developing a timeline around the next scheduled ACS trauma verification visit provided the team time to become familiar with the documentation tool, to address any issues that arose, and to obtain an adequate number of patient charts for review at the site visit.
After identifying key stakeholders and developing a timeline, the team evaluated the current paper documentation form to determine the critical information that was documented during a trauma. The paper documentation form followed the trauma nursing process as identified by the Trauma Nursing Core Course (TNCC) (Emergency Nurses Association, 2014). The current paper documentation form and key elements identified from both TNCC and the ACS verification guidelines guided the team in the development of the electronic documentation fields. D’Huyvetter and colleagues (2014) recommended that teams include an informatics specialist with ED experience when developing an electronic documentation process. The informatics specialist on the team integrated knowledge from past ED experience to hone the electronic document into a successful trauma narrator. The informatics specialist developed fields into the EHR one section at a time. The clinical trauma nurse end users reviewed each section of the trauma narrator as it was built. Their feedback was used to make revisions to the tool and ensure streamlined documentation.
After all sections of the narrator were approved by the inter-professional development team, the tool was vetted by 10 trauma nurses who were not involved in its development. In the fast-paced environment of the ED, one of the main challenges nurses face is keeping up with the documentation in the EHR. Therefore, feedback from end-users was critical. The nurses who reviewed the tool were hand-selected to provide feedback because they had excellent documentation skills on the paper forms. They were asked to review the narrator for completeness, flow, and ease of navigation. Revisions were made based on their feedback and a final version of the trauma narrator was approved by the development team.
Once the trauma narrator was approved, an educational plan was developed. A case review approach was used to guide the user training. Four trauma cases from the past year were selected to use for training. The names and ages of the patients were changed, but key nursing interventions and documentation needs were imbedded into the cases. The education was provided to teams in a computer room to allow live interaction with the trauma narrator. A member of the development team acted as a “driver” to guide the documentation on a screen, while another instructor led the case study. The “driver” documented in a simulated patient record on a projector screen so that nurses could follow the process. One of the clinical nurses on the development team circulated in the room to assist learners. Initially, seven sessions were offered and 60 nurses completed the training. Ongoing sessions are offered quarterly for new trauma team members. Evaluations of the trainings have consistently been ranked a 5.0 on our 0-5 Likert scale. Some of the comments from staff members who participated in the training included “practice in the playground helped me chart better and feel more confident,” “I liked the case scenarios that helped with hands on practice,” “Yeah! Computer charting for trauma patients,” and “Can’t wait to go live, loved the many examples.”
During training, the team identified that nurses would be less mobile when documenting electronically compared to when they documented on paper forms. When documenting on paper, the documenting nurse stood at the foot of the bed to visualize and capture care in the chart. With the transition to electronic documentation, the documenting nurse would need to be at a computer screen. The ED manager provided a sturdy movable arm to hold the computer screen and keyboard; the arm allows the trauma nurse to position him or herself in a manner to visualize the trauma patient while documenting electronically. An arm was installed in each of the trauma bays prior to implementation of the trauma narrator. The other finding identified during training was that there was not a method to document the trauma surgeon arrival time and the emergency medical services (EMS) pause; this documentation helps to ensure a timely hand off of care between the pre-hospital care personnel and the ED trauma team. The ED charge nurses decided to add the trauma surgeon to the daily ED team list in the EHR so that the primary trauma nurse could add the trauma surgeon into the team during documentation. The trauma team received education on the importance of the EMS pause, and an icon was added to ensure that this step was documented.
Once the education sessions were completed and issues identified during trainings were rectified, the trauma narrator went live (see Figure 1) after 12 months of development. The tool was used when documenting care provided to trauma patients. Electronic documentation was reviewed within 24 hours by the trauma program manager and immediate feedback and education were provided to individual nurses when errors were noted. Data were shared with the trauma core team through email correspondence and in quarterly educational offerings.
Since implementation, the trauma program manager reviews the key data points that are required for ACS verification documentation items for each case. Summary data providing trends in electronic documentation are shared with staff during staff meetings and at quarterly trauma educational offerings (see Figure 2).
All metrics are consistent with the exception of patient intake and output, which are much improved in the EHR. Data abstraction is easier and more consistent when obtained by report retrieval. Through data abstraction, staff feedback has been more consistent. It was noted that documentation of trauma surgeon arrival time was a missing field in some cases. This field is integral to the success of the trauma center verification process. The initial plan that was developed to document trauma surgeon arrival time involved adding the surgeon to the care team in the EHR. In our facility, the trauma surgeon arrival must occur within 30 minutes for critical activations, 60 minutes for urgent traumas, and four hours for the trauma consult. To facilitate documentation of this critical field, the tool was amended and a tab was added where the nurse could easily click to document the arrival of the trauma surgeon. This change has increased compliance with documentation of this required field (see Figure 3).
Overall, feedback has been positive and staff members have embraced the trauma narrator. Staff reported improvements that came from the transition to electronic documentation, including improved legibility and accessibility for physicians to review the patient care timeline and interventions.
An inter-disciplinary ED team, including engaged informatics team members, can effectively develop a well-planned electronic trauma record. Working with staff nurses lends a real world approach to development of an electronic trauma documentation tool. A willingness to spend the time on the ground work and develop a hands-on, case-based educational approach resulted in a positive outcome that improved trauma documentation, enhanced data extraction capability, and allowed all end users to visualize care in the ED. It was important for the team to realize that the first draft of the tool would not be the final version and to embrace continuous process improvement. As the tool has been used over the past year, there have been minor revisions to improve the flow of documentation and acquisition of key data elements. Ongoing monitoring and listening to team members’ feedback are integral to the success of the documentation process.
American College of Surgeons. (2017). Interim hospital preview questionnaire. Retrieved from https://www.facs.org/search?q=electronic%20documentation%20trauma%20nur…*
Bilyeu, P. & Eastes, L. (2013). Use of electronic medical record for trauma resuscitations: How does this impact documentation completeness. Journal of Trauma Nursing. 20(3). Doi: 10.1097/JTN.0b013e3182a17195
Coffey, C., Wurster, L., Groner, J., Hoffman, J., Hendren, V., Nuss, K., Haley, K., Gerberick, J., Malehorn, B., & Covert, J. (2015). A comparison of paper documentation to electronic documentation for trauma resuscitations at a
level I pediatric trauma center. Journal of Emergency Nursing. 41(1), 52- 56.
D’Huyvetter, C., Lang, A., Heimer, D., & Cogbill, T. (2014). Efficiencies gained by using electronic medical record and reports in trauma documentation. Journal of Trauma Nursing. 21(2). Doi: 10.1097/JTN.0000000000000031
Emergency Nurses Association. (2014). Trauma Nursing Core Course, 7th ed. Des Plaines, IL.
Jeannie Burnie, MS, APRN, AGCNS-BC, CEN, FAEN is the ED clinical nurse specialist at TriHealth, Bethesda North Hospital. She has 30 years of ED experience. She is certified by the American Nurses Credentialing Center as a board-certified clinical nurse specialist since 2010. She has been a certified emergency nurse for over 20 years. She has been the involved in many change projects and is viewed as a leader in the field of emergency nursing.
Christine Heist, MSN, RN-BC, has been a nurse for more than 19 years. She has practiced in the ED and intensive care unit and as an informatics consultant. She is certified in nursing informatics. Her experience in emergency nursing makes her a valuable asset during documentation development. During this project, Chris’s title was senior clinical informatics consultant. She has recently been promoted to senior application analyst.
Ellen Hardin, BSN, RN, CEN, has been a nurse for more than 12 years. She has worked in the ED for 11 years. She has been a member of the trauma core team for the past 10 years and is responsible for orienting new nurses to the ED and the trauma nursing process. Her experience as a staff nurse caring for emergency and trauma patients make her invaluable to the success of this project.
Katie Donoghue, BSN, RN, CEN has been an ED nurse for six years. She began her nursing career as a new graduate nurse in the ED new graduate internship program. She has become an expert nurse in caring for all patients in the ED, especially trauma patients. Katie is also a certified emergency nurse. As a staff nurse in the ED, Katie’s expertise is used to precept new nurses. Her excellent documentation skills made her the perfect choice for the multi-disciplinary team to develop an electronic trauma record.
Katie Dunigan, BSN, CEN, EMT-P, has been a nurse for more than 24 years. She has ICU, ED, and flight nursing experience. Katie is a certified emergency nurse and a paramedic. She is currently the trauma program manager at Bethesda North Emergency Department. She is responsible for the care and quality and process improvement for a level-three trauma center.
Kent Sheets, BSN, RN, has more than 25 years of emergency nursing experience. His current position is the senior application engineer for TriHealth Information Systems. Kent is well respected in the field of emergency nursing informatics. He is skilled at building emergency specific electronic documentation tools that are used across the six EDs in the system.