Dedicated trauma recorders improve documentation

The first trauma registries in the United States — developed in the 1970s along with trauma centers and systems — were small, hospital-specific reference databases of seriously injured patients. Hospitals still collect trauma patient information for their own use, but most now also submit data to state and national databanks.

In Minnesota, designated hospitals send reports to the Department of Health's statewide databank. Some centers also submit data to the National Trauma Data Bank, which contains more than 5 million records from U.S. trauma centers.

At all levels, registry data drives the quality improvement process, so incomplete data or inconsistent documentation directly affects a hospital's ability to provide better patient care. And because trauma flow sheets are the basis for billing, inaccurate documentation can also affect a hospital's bottom line.

Gail L. Norris, R.N., Southwest regional trauma program manager, knows the challenges of data collection firsthand. "The state will get billing information based on whether a patient is ICD-9 eligible for inclusion in the trauma registry, but that information isn't always accurate because different hospitals code differently," she explains. "I used to get pages and pages of discordant reports, so I had to go back and look at the patients the state thought should be in the trauma registry, but weren't. And what you find is that it all comes down to documentation."

To help upgrade the process at Mayo Clinic Health System in Mankato, Minnesota, Norris now has 15 dedicated trauma recorders, all with extensive on-the-job training. "The ED nurses are familiar with the trauma flow sheet and have a chance for input. But things get so wild and chaotic during a trauma resuscitation that you really need dedicated trauma recorders who are on the ball and know what's going on," Norris says.

She adds that the trauma flow sheet is the justification for billing and supports medical necessity. "A patient must have a minimum of 30 minutes of critical care in order for us to charge for it, so there must be evidence that someone was actually with that patient and doing something — taking vital signs, applying a cervical collar, starting IVs — the entire time. That's crucial for Medicare and insurance reimbursement."

But smaller hospitals where providers often play multiple rolls can struggle with documentation. "The recording nurses are a vital part of the trauma team," Norris says. "In a Level IV hospital with a small staff, the trauma recorder might be involved in other procedures, but ideally, you do want a dedicated trauma recorder. When you get caught up in the heat of the moment, it makes a huge difference."

Chris Ballard, R.N., EMT-P, trauma system coordinator for the Minnesota Department of Health, agrees. "When you're in a time-sensitive situation with so many things going on and everyone is focused on the task, the only way to get accurate documentation is to have a dedicated recorder. Measuring times and the action taken is important for measuring performance. And that comes from accurate recording of what happens from the minute the patient arrives at the door," he says.

Using registry data to drive policy decisions

In addition to injury prevention and evaluation of trauma patient outcomes, state trauma data is used for policy development.

"We have 125 trauma centers contributing to the state registry, which is enough data to drive policymaking decisions. But until recently, we haven't had an opportunity to use it," Ballard says. "We spent a lot of time and effort providing a framework for hospitals to report cases to us. Now we're moving into a phase where we can use that data to drive system-level performance improvement (PI) and hopefully establish some benchmarks."

One of the first benchmarks — expected to be established by mid-summer 2014 — is time spent out of definitive care, a big predictor of performance.

"You begin the quality improvement process by establishing standards you want to measure," Ballard says. "Trauma is so complex and broad you can't measure everything, but you can pick things that seem to be a problem. For instance, you pick a standard such as a Glasgow Coma Scale (GCS) score on every chart. After looking at a certain number of charts, you can see how the system is performing and then undertake PI initiatives aimed at improving that measure. Once you hit that goal, you start adding filters such as intubation of every patient with a GCS score of 8 or less. When you have mass data, you can start to measure that. Most small hospitals are just at the beginning, but it's a matter of 'First do this, then do that,' and one day you have a robust PI process."

To illustrate, Norris tells this story:

"Admission to nontrauma service was a big problem for Mankato five years ago. The American College of Surgeons says the number of patients admitted to a nontrauma service should be less than 10 percent. But our data showed that 12 percent of our patients were admitted to medicine without trauma or surgical services seeing them. So we took the issue to trauma performance improvement month after month, and finally things started to turn around."

But having the data to identify problems is just the beginning. The PI process itself remains challenging, Norris notes. "Once the issue is identified, a solution must be created to correct it. Then the change must be continuously monitored to ensure the correction has indeed occurred, resulting in loop closure of the issue."

Ballard adds: "In general, I think the concept of PI is very well-received. People recognize its value to their hospital and to patients. But my sense is that they're a little conflicted because PI costs money and doesn't generate any revenue. People recognize its value but wonder how they're going to find the resources to pay for it. The trauma billing code is intended to relieve some of these burdens and improve funding, but times are rough for hospitals," he says.

As for documentation, he notes, "From my perspective it's fairly simplistic. You write down what you did so people can see it. Hospitals in the state trauma system are volunteering to be regulated by a process that helps them meet standards. So there needs to be someone checking to see if they are actually doing what they say they are, and to do that, we need to be able to rely on what people have written along the way."