Trauma DocumentationandTrauma Triage

North Country EMS ConferenceOctober 17, 2004

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

Trauma triage stepsTrauma communication / report formatTransport decision making

Completion of the NH BEMS PCRGeneral PCR guidelinesSOAP format17 Key Data Fields

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

Why is good documentation essential?Resource Guide & Power Point:Available for download at:http://www.nh.gov/safety/ems/traumapresentations.htmlIf it was not documented, it was not done!Reflects adherance to the standard of care.

Saf-C 5902.07Recordkeeping and ReportingRecordkeeping 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 5902.08PCR 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.

Trauma System GoalTo get the right patient to the right hospital at the right time.

Trauma Statistics NHLeading cause of death in people age 1-34#1: MVCs#2: Firearms#3: Falls5th leading cause of death overall1/3 intentional2/3 unintentionalSomeone in NH dies of trauma every 20 hours

When Do Trauma Patients Die?% of DeathsSevere Head or CV InjuryMajor Torso or Head InjuryInfection and MSOF

Organized Trauma Systems Death & Disability Through:Injury PreventionSystem PlanningEvaluation & MonitoringCommunication / Collaboration / Teamwork

NH Trauma System Development1980s: Exclusive Regional Trauma SystemEach of the 5 Regions was asked to make Trauma Center designationsNot successful 1992 & 1994: Inclusive Statewide Trauma System PlanGrants from HRSA

NH Trauma System Development 1995: Statewide Trauma Plan FinalizedSenate Bill 122Trauma Coordinator position createdTrauma Medical Review Committee named as the Oversight Committee Bureau of EMS named as the Lead Agency

NH Trauma System Development 1999: Trauma Triage, Communications, and Transport Decision Making Educational Program offered2002: TEMSIS Grant year 12004: Trauma Documentation and Trauma Triage Resource Guide & Train-the-Trainer Program

NH Trauma System ComponentsPrevention & Public EducationHospitals & EMS ProvidersMedical Direction: On-line & Standing OrdersTriage & Transport GuidelinesRehabilitationEvaluation

Need to Know InformationHospital AssessmentTrauma Triage GuidelinesCommunication GuidelinesTransport GuidelinesResources available to you

Hospital AssessmentPerformance LevelsInitial, Advanced, or LeadershipRolesArea or RegionalCapability LevelsAdult & Pediatric; Level I, II, or III

Hospital AssessmentCapability LevelsAdult & Pediatric; Level I, II, or III

Hospital Assessment:ProcessHospital Staff Self-AssessmentSite Visit by Members of TMRCConfirmation Consultative / Assistance

New Hampshire Trauma Facility Assignment

New Hampshire Department of Safety

Division of Fire Standards & Training

Bureau of

Emergency Medical Services

May 2004

Key to Hospital Trauma Levels

Level I

Level II

Level III

Upper

Connecticut

Valley

Androscoggin

Valley

Weeks Medical

Center

Dartmouth-Hitchcock

Medical Center

Cottage

Alice Peck Day

Memorial

Valley Regional

Littleton Regional

Cheshire Medical Center

Monadnock Community

St. Joseph

New London

Franklin Regional

Southern NH

Medical Ctr.

Portsmouth Regional

Elliot

Catholic Medical Center

The

Memorial

Lakes Region General

Speare Memorial

Frisbie Memorial

Huggins

Concord

Parkland

Exeter

Wentworth-Douglass

US Veterans Admin.

What is Trauma Triage?Patient Needs Hospital Resources

Trauma patients are assessed and transported to the most appropriate hospital for that patients injuries.MATCH

Trauma TriageGoal: Right Patient to the Right Hospital at the Right TimeOVER Triage:Minimally injured pts Trauma CentersResult: Overburdens the system, no ill effect on pt careNot SO badUNDER Triage:Severely injured pts Non-Trauma Centers Result: Hospitals may not be equipped to treat the pt and pt care may sufferCan be VERY BAD!

Steps to Trauma Triage AccuracyKnow the Trauma Triage and Transport Pathways CardAvailable through NH Department of Safety & EMS-C programBe familiar with severity indicators (GCS & RTS)Listen to your gut (sick v. not sick)Know your local resourcesOn Scene: Mutual Aid, ALS Intercept, Air TransportHospital: Local Hospital capabilities, distance to Regional Trauma Center

Front of CardSeverity Indicators are based on:PhysiologyAnatomyMOI & Comorbid Factors

Back of Card

Scales & ScoresTrauma Communication

Trauma Triage Steps: To RecapUse Pathway Card to determine Pt StatusTrauma Triage CommunicationContact Medical ControlRelay enough info to aid in decision makingTransport Decision Transport

Scenario 1

Scene InfoMotorcycle v. Pickup TruckTruck traveling 40 mph, ? Cycle speed30 y/o male thrown 20 feetTruck has damageRiders helmet has few, minor scratches

What does this information provide us?What additional information do you need?

Initial AssessmentAirway is open and clearOpens eyes to loud verbal stimuliLocalizes painful stimuliConfused verbal response to questionsRR=32, chest expansion, R. wall bruisingStrong radial pulses, no major bleedingSkin pale, moist, cool

Can you estimate GCS & RTS?What is the Patient Status?

Focused H&PNo obvious head injury, PERRLANo JVD or tracheal tugging, C-spine non-tender Chest expansion, crepitus, lung sounds R.Abdomen soft, but guarding; pelvis stableOpen L. femur fractureAbrasions and small laceration on R. armPulse = 100, BP 110/68, RR = 32Medic alert tag for Coumadin use

Confirm or dispute your initial severity determination.

Trauma Communications

What pertinent information will you communicate to medical control?

MIVT

Transport DecisionInjury SeverityHospital capability, location, driving timeArea Level III Trauma Hospital is 10 minutesRegional Level II Hospital is 20 minutesALS intercept is unavailableHelicopter is available and ETA to scene is 20 minutes

What decision will Medical Control make?Why?

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

General PCR GuidelinesComplete a PCR for every call and every ptThis includes when care or transport was:RequestedRenderedRefusedCancelledThis includes pts treated by one agency and transported by another. >1 PCR may be generated for the same pt/pt encounter.

General PCR GuidelinesA written PCR is:CompleteAccurateLegibleProfessionalBe:ObjectiveBriefAccurateClearLegible Handwriting & Correct Grammar and Spelling are a must!Poor documentation = Poor care

Changes to the PCRDO NOT use white out or any correction fluid/tape DO NOT try to obliterate or destroy informationIt 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 documentationDO NOT leave blank or empty lines or spaces!

Addendums to the PCRIf 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 agencySecond copy shall be retained by the receiving hospital/facility

Addendums to the PCRThe addendum shall also contain:The date of the callThe 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 PCRWho started care before you arrivedHow you found the patientAnything you found during your assessmentPertinent (+) and (-) findingsAnything you did for the patient & their responseWhere you left the patient (& with whom)Report given (to whom) & questions answeredCondition of the patient upon termination of carePIVs patent? MAE=x4? ETT position verified?If you did it, you should write it (& vice versa)

Within Normal LimitsOrWe Never Looked???????

What NOT to Write in a PCRAny foul or objectionable languageAnything that could be considered as libelExample: 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 DocumentationPatients ABLE to refuse care include:Competent individuals defined as the ability to understand the nature and consequences of their actions ANDAdult defined as 18 years of age or older, except:An emancipated minorA married minorA minor in the military

Refusal DocumentationPatients 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 signsMental retardation and/or deficiencyAny patient who makes clearly irrational decisions in the presence of an obvious potentially life or limb threatening injury, including persons who are emotionally unstableAny 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 circumstancesUnder age 18 (except as denoted above)

Refusal ProcedurePerform a complete exam with vitalsIf refused, document thisDetermine if the patient is competent to refuseEnsure the pt or responsible party:Has been told of his/her conditionUnderstands the risks or refusalAssumes all risk & releases EMS from liabilityUnderstands he/she can call you back anytime

Narrative Charting

SubjectiveAny information you are able to elicit while taking the patients history:Chief Complaint (CC)History of Present Illness (HPI)OPQRST AS/PNPast Medical & Surgical HistoryMeds and Allergies

ObjectiveGeneral ImpressionPrimary AssessmentABCDESecondary AssessmentHead to Toe Exam

AssessmentField DiagnosisWhat you believe the problem to beWorking diagnosisExample: Chest pain, R/O MI; closed head injury with altered LOC; pelvic fracture

Plan / ManagementTreatmentPatient ResponseExample: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 Charting

CHARTChief ComplaintHistoryAssessmentRxTransport

Demographics3 Key Trauma Fields

EMS Response TimesKey Trauma Field

Vital Signs4 Key Trauma Fields:Pulse, SBP, DBP, RR

Lung Sounds, Pupils, Skin, TempKey Trauma Field

GCS & RTS4 Key Trauma Fields:GCS EyeGCS VerbalGCS MotorGCS Total4 Key Trauma Fields:RTS GCSRTS BPRTS RRRTS 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

ExamDescriptorAssigned GCS ScoreEye Opening ResponseSpontaneous4To Voice3To Pain2None1Best Verbal ResponseOriented5Confused4Inappropriate Words3Incomprehensible Sounds2None1Best Motor ResponseObeys Commands6Localizes Pain5Withdraws (pain)4Flexion (pain)3Extension (pain)2None1Total GCS11

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

GCS of E3-V4-M4=11

SBP of 92

RR of 12

ParameterValueAssigned RTS ScoreGlascow Coma Scale (GCS) Total points13-1549-1236-824-5130Systolic Blood Pressure (SBP)>89 mm Hg476-89 mm Hg350-75 mm Hg21-49 mm Hg1No Pulse0Respiratory Rate (RR)10-29/min4>29/min36-9/min21-5/min1None0Total RTS: ____11__________

Why do we collect data?Benefit patient careProvide feedback to the EMS agency/providerEvaluate system performanceDetermine if the patient treatment protocols are working for the patient population servedDesign injury prevention programsPerform quality assuranceOutline opportunities for improvement in data collection and the reporting system

Examples of ReportsResponse timePerformance, such as ETI success ratesProcedures, such as number of IVs per provider per yearNumber of CPR calls

Difficulties

Garbage ingarbage out.

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

17 Key Trauma Data FieldsOn ScenePt StatusPulseResp RateSystolic BPGCS TotalGCS EyeGCS MotorGCS VerbalDiastolic BPRTS TotalRTS GCSRTS Resp RateRTS BPTrauma Patient?TemperatureTrauma Team Activated?

Field Name% of Total Trauma Calls ReportedOn Scene Time92.8Patient Status73.9Pulse72.4Respiratory Rate66.4Systolic BP66.1GCS Total59.1GCS Eye59.0GCS Motor59.0GCS Verbal59.0Diastolic BP56.0RTS Total49.7RTS GCS49.5RTS Respiratory Rate49.1RTS BP49.1Trauma Patient?4.4Temperature0.0Trauma Team Activated?0.0

Approved AbbreviationsA complete list is available in the accompanying Resource Guide

Data DictionaryClearly defines each data field and how to fill in the corresponding box on the PCR.

Available through the State Office.

SummaryTrauma 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?

Thank You.

This is a Train-the-Trainer format In EMS, we are all used to See One, Do One, Teach One

In this presentation, we will be going through the slides to give you a feel for the general content AND ALSO talk about ways to present the information, additional resources, etc.

**Go through contents of their packet/folder

**Discuss ways to use the material classroom, self studyDocumentation and data collection focus will be on the 17 Key Trauma Fields currently being tracked on a statewide level.**The Resource Guide is undergoing some revisions, but will be available from the NHBEMS in the not to distant future. - The Resource Guide contains more detailed resource information than this presentation. - This presentation contains the Need to Know information items that are considered critical for all EMS providers in the state to be aware of.Why are we having this discussion/class?

The New Hampshire Code of Administrative Rules describes Recordkeeping & Reporting requirements.

*at this point in the class, the I/C can show the PCR - each section will be reviewed in detail later in the course.Right Patient: Minimize (can never avoid) over- and under-triageRight Hospital: Know hospital assignment & capability levelsRight Time: Golden Hour & decreasing time to definitive care1st: MVC (inc. MVC, MCA, bicycles, pedestrian, etc.)2nd: Firearms (87% suicides)3rd: Falls(data from 1992-1996)AN EXAMPLE of what a Trauma System can do/accomplish:17 y/o male 1 hour 45 minute extricationCamaro high rate of speed on a rural road.No EtOH lost control around a curve. Departed the roadway and hit a tree.+Seatbelt (his mom reminded him before he left the house)His friend was not wearing a SB and was ejected. Pronounced DOA on the scene.Air Medical helicopter called to the scene to assist with pt care during the extrication (PIVs, RSI, blood administration).Pt flown to Level I Trauma Center. 20 minute flight (1+ hour drive to Level I; 20 minute ride to Level III)Injuries: spleen, liver, pelvis fx, lower extremity fxs, required amputation below knee of left leg.Left the hospital ~ 2 weeks later.Very grateful for the care he received & the fact that he lived. Immediate (>50%): Occur at the time of the injury and are generally a result of severe head or cardiovascular injury. The only possible intervention for this group is an aggressive prevention program through public awareness and education. (Concept of preventable trauma - youll notice that it is no longer called a motor vehicle accident ---it is now a motor vehicle crash)Reduction in mortality must occur through injury prevention: Drunk driving prevention; Seat belt/child safety seat usage; Motorcycle and bicycle helmet usage; Gun safety; Burn prevention

2. Early (30%): Occur during the first few hours following injury as a result of major torso or head injury. Many early deaths are preventable with appropriate care. The concept of the Golden Hour is derived from this group.Reduction in mortality is achieved with a systems approach and attention to the Golden Hour: Standardized patient care practice and rapid access to advanced life support; Standardized trauma triage and transport to an appropriate trauma care hospital; Immediate evaluation and resuscitation of all trauma patients in the ED by trained emergency or surgical personnel; Comprehensive intervention for major single-system and all multi-system trauma patients by experienced trauma surgeons; Utilization of a team approach with preplanned trauma response; Priority availability of all related hospital resources for the care of the injured patient (radiology, laboratory, blood bank, operating room, etc.)

3. Late (15-20%): 2-4 weeks out. Occur as a result of infection or multisystem organ failure. Often due to inadequate initial resuscitation. Can potentially be affected by improvements in early care during the resuscitation phase.Reduction in mortality involves the work of high-quality medical and nursing care on a 24-hour basis:Establishment of an intensive care unit dedicated to the needs of the critically injured adult and child; Specially trained physicians, nurses, and other allied health providers; Ongoing, continuing education for all professionals working in trauma care; Ongoing, continuous research into trauma prevention, pathophysiology, treatment, and outcome

Reference articles provided in handoutInjury Prevention public educationSystem Planning e.g. this class (trauma triage & transport, hospital assignment)Evaluation & Monitoring QI process, loop closureCommunication/Collaboration/ Teamwork - + working relationships

Benefits of a successful Trauma System include: a reduction in deaths caused by traumaa reduction in the number and severity of disabilities caused by traumaan increase in the number of productive working years seen in America through a reduction in death and disabilitya decrease in the costs associated with initial treatment and continued rehabilitation of trauma patientsa reduced burden on local communities as well as the Federal government in the support of disabled trauma patientsa decrease in the impact of trauma on victims and their families.

Cite studies here --- Reference articles in handout50-60% of trauma deaths are preventable with a Trauma Care System (reference: 1999 Trauma Education Program) Thirty years of experience has brought much change to how Trauma Systems are organized. During this time, the focus has shifted from Trauma Centers to Trauma Systems, exclusive to inclusive systems, and categorization to designation of acute care facilities. One thing has remained steady regarding the benefit of Trauma Systems: organized Trauma Systems save lives. Findings from several studies indicate trauma mortality is reduced by 15-20% when the very seriously injured are treated at trauma centers versus non-trauma centers. It is estimated that 50-60% of trauma deaths are preventable with comprehensive trauma system implementation.

Effects may take 10 years to be apparent due to: maturation and development of trauma triage protocols, interhospital transfer agreements, organization of trauma centers, and ongoing quality assurance.In the early 1980s New Hampshire began to look at Trauma System development. Initial effort focused on creating a regional Trauma System that worked within the existing EMS regions. Each of the five New Hampshire Regional Councils was asked to make Trauma Center designations based on the Exclusive Trauma System Model. Under the exclusive model, trauma care resources were limited to a small number of designated facilities. These hospitals were promoted as the only ones that could care for trauma patients within a particular area. Exclusive Trauma System efforts were not successful across the state due to several factors including New Hampshires geography and weather, wide variations in population density, and the different trauma center capabilities of hospitals in the five regions.In 1992 and 1994 New Hampshires Bureau of EMS received two trauma care system planning grants from HRSA for the development and implementation of a statewide inclusive Trauma System. The concept of an inclusive Trauma System recognizes the need for all hospitals that treat and admit trauma patients to participate in the Trauma System, regardless of geographic location, population density, and/or severity of the patients injury. The planning process indicated that a successful Trauma System in New Hampshire must integrate all health care resources available in the state and avoid fragmenting trauma care. *Plan was finalized in 1995.New Hampshires Statewide Adult and Pediatric Trauma Plan was finalized in 1995 and enacted into law by the Legislature via Senate Bill 122. A Trauma Coordinators position was created and a stakeholders group was formed. The Trauma Medical Review Committee was named as the Trauma Systems Oversight Committee and the New Hampshire Bureau of EMS was named as the Lead Agency. Full implementation of the Trauma System, including data collection, evaluation, and quality improvement, has not occurred. The Trauma Systems impact on the process of trauma care and patient outcomes has not been analyzed. Participants in the 2001 Trauma System stakeholders meeting cited New Hampshires lack of data collection, monitoring, and feedback as key weaknesses and called for opportunities to advance hospital participation, data collection, and quality improvement. Action plans are currently underway to accomplish these things. Two main goals are: 1) to enhance Trauma and EMS System evaluation resources and capabilities by creating a Trauma-EMS Information Systems Committee responsible for the development of an evaluation system action plan and 2) to enhance trauma patient care reporting capabilities to strengthen the States out-of-hospital database by hiring a half-time trauma documentation project coordinator and identifying key trauma data fields and monitor for reporting compliance. In the fall of 1999, a Trauma Triage, Communications, and Transport Decision Making Educational Program was rolled out to prehospital instructors in New Hampshire. A tool kit for lead Emergency Medical Technician (EMT) Instructor-Coordinators (I/C) at all levels was prepared and distributed during a series of workshops throughout the state. Curricula, a power point presentation, and resource materials were provided to EMT I/Cs. From there, a statewide educational effort was underway with the goal of having all prehospital providers using the same set of Severity Indicators for identifying high risk trauma patients. Also addressed in this program was a standard format for radio communications and transport decision-making options.

TEMSIS: Trauma EMS Information Systems. Goals: Develop information systems that are able to describe an entire EMS event; Adopt a uniform data set/definitions; Develop mechanisms to generate and transmit data that are valid, reliable, and accurate; Develop integrated information systems with other health care providers, public safety agencies, and community resources; Provide feedback to those who generate data.

Grant funding from a statewide rural health initiative has helped continue to support this ongoing effort. This Trauma Documentation and Triage Resource Manual and train-the-trainer program represents a continuation of those efforts. EXAMPLES/DATA:Prevention & Public Education: seatbelt & helmet use (although not mandatory in NH), Shattered Dreams type programs, Car Seat education/useHospitals & EMS Providers: NH has >4,600 providers, 60% volunteer, primarily EMT-B level. >96,000 requests/yearMedical Direction: On-line & Standing OrdersTriage & Transport Guidelines: e.g. this program, triage card, state trauma planRehabilitationEvaluationWHAT are your local hospitals capabilities?

What status is your patient? What are the patients needs?

Early and continued communication with Medical Direction and the Trauma Center is a must.

Transport decisions in cooperation with Medical Direction.There are three Levels of Performance: Initial, Advanced, and Leadership. The Performance Levels are the same in both the Adult and Pediatric Trauma Systems. Today, the system has only clearly defined the Initial and Advanced levels:Initial Level:A staffed Emergency Department open twenty-four hours a day (*has NOT participated in a site visit)Advanced Level: (*has participated in a site visit)Hospitals complete the Self-Assessment ToolHospitals voluntarily participate in the On-Site Review ProcessThese hospitals are required to submit data requested to the Lead Agency, which is NH BEMS (& or thru? The Trauma Medical Review Committee)

Once a hospital chooses to participate at the Advanced Level, they are asked to declare their role in the receiving and transporting of patients. The Roles defined in both the Adult and Pediatric plans are: Area: Area Hospitals receive trauma patients from their own catchment area and transfer out patients that exceed their clinical capabilitiesRegional:Regional Hospitals receive trauma patients from their own area as well as transfers from Area Hospitals. These Roles are the same in both the Adult and Pediatric Trauma SystemsIt is within the criteria for Clinical Capability Levels that our System requires hospitals to declare what patients they are fully capable of managing and what patients need to move on to another facility, either from the scene or as an interfacility transfer. It is here that an entire institution makes a commitment, versus the effort of a single provider or department: the entire system must be capable of caring for the types of patients identified. In New Hampshire there are Level I, II, and III Trauma Hospitals:

Level III Trauma Hospitals: Provide initial care for trauma patients. At this level, hospitals provide prompt assessment, stabilization, resuscitation, and emergency surgery for trauma patients. They have a plan in place for the rapid identification and transfer of most moderate to all severely injured patients to a Hospital of higher Clinical Capability. Typically Level III Trauma Centers are community hospitals that do not have ready access to a definitive trauma care facility (Level II and I). They are required to have a General Surgeon available within 30 minutes. Level III Pediatric Trauma Hospitals transfer out all severe are moderately injured patients.

Level II Trauma Hospitals: In New Hampshire provide initial definitive care for a majority of trauma patients from their area. The exception here would be a more complex multi-system trauma patient. These patients require advanced and extended surgical and critical care. As an institution they have decided what patients rise above the threshold for admission, and have a plan in place for expedient transfer. For the patients that meet the admission criteria of a Level II, a plan for a multi-disciplinary team response to the Emergency Department must be in place, including a General Surgeon and Neurosurgeon within thirty minutes. As a Level II Pediatric Trauma Hospital, patients with an ISS of 29, MOI +Decision not to request air transport via Medical Control due to travel times by ground to a Regional Level II Trauma HospitalKey Points:Review the importance of pre-planning your service area resources, advanced life support, and air medical transportReview the importance of recognizing early which patients need to go to what Level Trauma Hospital and how to communicate to Medical ControlReview the significance of using Status Determinations and early trauma communication with the hospitalReview Trauma Triage criteria that providers should utilize when making transport decisions, including air medical transport

Insert your own sample radio reports here...Consider taking a BREAK here - this is about 1/2 way through the presentation.If multiple agencies with different levels of care respond to the same patient (for example, BLS providers, who then call for ALS intercept, who then call for a helicopter) each agency should complete a PCR documenting the care they provided to the patient.

If multiple agencies respond on 1 patient, the PCRs will be linked (using Probabalistic Linkage linked by at least 2 data points to ensure they are the same person)Complete:The PCR should be precise and comprehensive. Include all relevant information that might be pertinent now or at a later date. Exclude all superfluous information. You should complete both the check box and the narrative portion of the PCR. The narrative is the core of the PCR. INCLUDE pertinent POSITIVES and NEGATIVESAccurate:Correct spelling and grammar, as well as use of only approved abbreviations and acronyms are essential. Misspelled words may lose their meaning, or worse, be used in court as proof of bad care. Non-approved abbreviations may be misinterpreted. Several acronyms have more than one meaning it is best to utilize only acronyms and/or abbreviations that have been approved by the State or the EMS agency.Legible:Penmanship must be neat, as several people may rely on the information contained in your report. Also, you might be called upon to review your PCR for legal proceedings in the future. Often, legal proceedings take place several years after the event. Not only will your PCR serve as your proof that you adhered to the standard of care, it also may jog your memory as to the events in question.Professional:Your PCR may be viewed by several people: hospital staff, quality improvement committees, supervisors, attorneys, the media, the patient and/or the patients family. Write your report in a professional manner, avoiding any remarks that might be construed as derogatory. A seemingly innocent phrase or use of jargon may come back to haunt you at a later date.Per RSA

Many agencies use a second PCR as the addendum and route the copies in the same manner as the original PCR. Just make sure you clearly label it as an addendum (as the new PCR will also have a PCR number).

questions answered document the fact that you answered any questions that you were asked. You do not need to document the individual questions you were asked. Also consider documenting all care assumed by ____________ It is especially important to document pt status at handoff, and patency of all procedures you performed (PIVs, ETT, etc.) It is okay to use quotes from the pt or to objectively describe the pts behavior (I.e. pt swinging arms with clenched fists at EMS personnel and stating Ill gonna kill youIt is important to note that a PCR that fails to document an orientation level or a physical assessment does not verify that the standard of care was met. Other than a tool for communicating credibility and clinical competency, the PCR can be used to document the patients verbal responses and interactions with those attempting to provide care. Quotes from the patient, especially if they are hostile in nature, can potentially speak volumes to a jury about the potential character of the patient. According to EMS and the Law, A Legal Handbook for EMS Personnel (Goldstein, A. Fairfield: Prentice-Hall, 1983), all patient refusals should be accompanied with a written release that, at a minimum, contains the following:The patient has been told of his or her conditionThe patient understands the risks of refusalThe patient refuses transport (or whatever assistance was offered)The patient assumes all risksThe patient releases EMS personnel from liabilityEven so, this may not be enough! Refusals of medical care in the prehospital setting occur at a relatively high rate and non-transport of a patient is the most common prehospital care event leading to litigation. Oftentimes, patients are unable to recall instructions and the risks as explained to them by EMS personnel. Cases of informed consent are the most common ethical conflict prehospital providers face.Experts recommend the following twelve items be included in refusal documentation:Physical examination to include vital signsHistory of event and prior medical history to include medications obtainedPatient or decision-maker determined to be legally capable of refusing medical careRisks of refusal of medical care and transportation explainedPatient clearly offered medical care and/or transportationRefusal of Care Form prepared, explained, signed, and witnessedPatient confirmed to have meaningful understanding of the risks and benefits involved in the medical care decisionPatient advised to seek medical attention for complaintPatient advised to call 911 for medical attention if condition continues or worsensBase consultation occurred according to local policySupervisor was notified if any of the above was not accomplished SUBJECTIVE: what they tell youChief Complaint (CC): What the patient tells you the problem is. Example: I have pain in my chest. Use quotes whenever possible.History of Present Illness (HPI): For most chief complaints, the OPQRST - ASPN pneumonic may help the provider recall important questions to ask the patient. Remember to ask open-ended questions: What does the pain feel like? NOT Is it sharp?O OnsetDid the problem develop suddenly or gradually? What was the patient doing when it started?P Provoke and PalliateProvoke: Does anything make the pain worse? Often, movement, deep inspiration, etc. can intensify pain. Exertion can intensify respiratory difficulty.Palliate: Does anything make the pain better? Did the patient take any medication prior to your arrival bronchodilators, nitroglycerine, etc.? If so, did it help? Did the patient change position e.g. sitting bolt upright? If so, did it help?Q Quality: What does it feel like? It is important to ask open-ended questions, not questions where the patient can answer yes or no. Example: What does it feel like? NOT Is it sharp? Quote the patients description in the PCR.R Region and Radiation: Where is the symptom located? You can ask the patient with pain to point to where it hurts. Does the symptom move/migrate/radiate anywhere else?S Severity: Number scale from 0-10. 0 = no pain, 10 = the worst pain the patient has ever experienced. If the patient can not understand the 0-10 scale, try using mild, moderate, or severe. Look at the patients appearance are they grimacing and diaphoretic? With children, you can use the faces scale ask the child to point to the face diagram that looks like how they feel T Time: When did the symptoms begin? Is it constant or intermittent? How long has it lasted? Any previous episodes?

AS Associated SymptomsExample: In the patient with chest pain, inquire about associated shortness of breath, nausea, dizziness, etc.PN Pertinent Negatives Are any likely associated symptoms absent? This information might help rule out a particular illness or injury. Example: the patient with chest pain who does not complain of any shortness of breath, nausea, or dizziness but who does complain of increased pain with palpation or movement. Example: Sudden onset chest pain while walking to mailbox. Pain worsened while walking inside and got slightly better with rest. Patient took three sublingual nitroglycerine tablets without any relief. Patient states it feels like a horse is sitting on his chest. Pain is sub-sternal, with radiation into the right side of the jaw. Patient rates pain a 5/10. Symptoms present for 20 minutes now, constant. Associated with slight nausea and shortness of breath. Past Medical and Surgical History (PH)Example: Patient has a history of angina and insulin dependant diabetes mellitus.OBJECTIVE: what you seeThis includes your general impression and any data you find through inspection, palpation, auscultation, and percussion while performing your physical assessment of the patient.A Head-to-Toe approach can help with a systematic and thorough assessment.Example:General Impression: The patient presents in moderate distress, sitting upright on his living room couch.Vital signs: BP 146/82; Pulse 82, strong and regular at the radial site; Respirations 18, slightly labored.Neuro: Awake, alert, oriented x4. Pupils PERRLA @ 4mm. MAE =x4.HEENT: No signs of traumaNeck: Trachea midline, no JVDChest: Lung sounds clear, equal bilateral. Pulse oximeter 98% on 4 lpm via NC. Cardiac monitor shows sinus rhythm without ectopy.Abdomen: Soft, non-tender. Bowel sounds present x4 quadrants. c/o slight nausea, no emesis at present.GI/GU/Pelvis: Stable pelvis, no changes in bowel or bladder habits.Extremities: CMS present in all extremities. Pulses 2+ radial and pedal, no peripheral edema.ASSESSMENT: What you think the problem/diagnosis isThis is where you document what you believe the patients problem to be. This is also known as your working diagnosis, field diagnosis, or impression.Example: chest pain, rule out unstable angina versus acute MIPLAN/MANAGEMENT: What you plan to do about the problem & what the pts response isRecord what you plan on doing or what you did for the patient, from start to finish. This includes how you packaged and moved the patient to your stretcher and ambulance. List any interventions initiated prior to contacting your medical control physician. For example, did you apply oxygen and start an IV? Describe any orders from your medical control physician, and include his or her name. Describe how you transported the patient and the effect of any interventions (treatment modalities, medication administration, etc.) you performed. Include any ongoing assessments/reassessments and any changes in the patients condition. Finally, document the patients condition upon arrival to the hospital and who assumed care of the patient. If you have intubated the patient or started an IV, document proper placement or patency at hand-off.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.**An important component of documentation not directly addressed by the SOAP pneumonic is reevaluation, or patient response to plan/treatment. It is crucial to document this aspect of care! For example: chest pain decreased from 4/10 to 1/10 with O2.Just another acronym to help providers remember what elements to chart on the PCRRx = treatment renderedConsider a BREAK here

I/Cs may choose to go over each element of the PCR (for example with new providers) also using actual PCRs from that service as additional teaching examples.

For the TtT class, the focus will be on the 17 key trauma data elements the State is monitoring on/focusing on (The long ppt version on the website covers every field on the PCR)

**At their agency, they will most likely choose to go through every field, not just the 17 key trauma data fields.

**Encourage TtT participants to use actual PCRs from their agency as additional teaching examples. Can use overhead transparencies use GOOD examples and examples which show OPPORTUNITIES FOR IMPROVEMENT. Mark out any names or other identifying information (cert #s, etc.)SERVICE Indicate responding EMS service name and NH License # (assigned by the BEMS).NH Lic # Indicate responding EMS service NH License # (assigned by the BEMS).DATE Month, Day, and YearCall # This is the number your service may have assigned to the call (local option).DISPATCHED TO Name of medical facility or physical address of the call (street, city, state).PATIENT NAME The patients full name (last, first, middle initial) and home telephone number on line 1. The physical address where the patient resides (city, 2-letter state abbreviation, zip code) on line 2. The patients full name and street address will be obscured on the BEMS copy of the PCR. D.O.B. Patients date of birth month and day in 2-digit format (02, 12, etc.); year in 4-digit format (1955, 1999, etc.).AGE Patients age. Numeric value: 0-100.Sex Check the appropriate box with an x: M for male and F for female.Weight Enter a number and indicate if this is in pounds lbs or kilograms kgs (2.2 lbs = 1 kg). NOTE: it is generally more acceptable to document weight in kilograms. To calculate the # of KG, divide the patients weight in lbs by 2.2. Example: 220 lbs 2.2 = 100 kg.

** Patient Status Severity of patient injury or illness:1: Emergent - A critically ill or injured patient who needs immediate attention and therapeutic intervention. Delays could potentially threaten life or function.Examples: cardiac arrest, respiratory arrest, acute chest pain with unstable vital signs, allergic reaction with acute respiratory distress and shock, severe shock, severe trauma (2 or more systems, gunshot wound, or stab wounds to head, neck, or truck; severe, uncontrolled hemorrhage).2: Urgent - Less seriously ill, but requiring prompt therapeutic intervention to minimize the danger. Short delays in therapy will not seriously endanger patients condition.Examples: possible heart attack, congestive heart failure, asthmatic attack, overdose, hypo- or hyperglycemia, burns (2nd or 3rd degree over at least 20% of body surface or over entire face), grand mal seizures, serious fractures with possible internal injuries, hemorrhaging but with stable vital signs.3: Non-Urgent - Not seriously ill or injured, but still requires transport to hospital. Medical attention required but with patients condition not endangered by even prolonged wait.4: Does not require ambulance transport - Patient may not need medical attention. Patients condition does not require ambulance transport.** Trauma Score Number achieved using the Revised Trauma Score (RTS).NOTIFY Name of person to notify (relationship and telephone number).** Trauma Team Activated Check the box if the receiving hospital trauma team was activated for patient care.EMS RESPONSE TIMESUse Military time (2400 clock) always four digits. Range will be 0000-2400. Here are some examples:12:01 am = 00016:01 am = 060112:01 pm = 12016:01 pm = 18019:01 pm = 210111:59 pm = 2359Midnight = 2400The times you enter on the PCR are considered the official times of the incident. Ensure their accuracy! Whenever possible, record all times from the same clock. When this is not possible, synchronize watches/clocks you use.TIME Use 24-hour (military) time.L.O.C. Circle One: A: Alert and oriented (person, place, and day) V: Responds to verbal stimuli (call patients name); Patient can verbalize, but is not oriented to person, place, and day P: Responds to painful stimuli only (pinch, nail bed pressure) U: Unresponsive

PULSE Enter rate (beats per minute). Check the quality: Regular Irregular Strong WeakBP Enter systolic and diastolic numbers. If taken by palpation, enter P in place of diastolic pressure. Examples:124/78, 90/PRESPIRATIONS Enter rate (breaths per minute). Check the quality: Normal Abnormal Labored Shallow

**Ideally, there should be at least two full sets of vital signs.**Document orthostatic/postural vital signs as appropriate and indicate patient position by drawing stick figure: supine, sitting, standing.**If the patient is on the cardiac monitor, describe the rhythm and attach a rhythm strip LUNG SOUNDS Record presence of absence of lung sounds in both lungs. Check applicable descriptors for each lung: Clear Absent Stridor Rales Rhonchi WheezesPUPILS Check all that apply for each eye: Reactive Unreactive Constricted Dilated Check if applicable for both eyes: Unequal Disconjugate Document size (in mm) of each pupil. Use the diagram as a guide.SKIN Check all that apply: Normal Cyanotic Moist Flushed Pale

TEMPERATURE: Temperature is an essential vital sign to record. Check the applicable box: Normal Warm/Hot Cool/Cold Document the patients actual temperature (number) and indicate if it is in Celsius or Fahrenheit. Ideally, document an initial temp and the pts temp at handoff - in addition to whatever means you used to re-warm the pt or keep the pt warm.Trauma Patients who are allowed to get hypothermic do worse! This is perhaps the most confusing part of the PCR for most providers! The Glasgow Coma Scale (GCS) is an objective measure of the extent and progression of neurologic injury. The basis for the GCS is the response of the patient to the rescuers three specific requests: Eye Opening, Verbal Response, and Motor Response. The patients response is assigned a number, as outlined here. The higher the score, the more responsive the patient is to the rescuers commands. The highest score possible is 15; the lowest score possible is 3. It is important to note the GCS is based on the patients BEST response. The GCS scores the patients response in regard to the patients injuries, not to treatment (sedation, pain medication) rendered.

**Over the next few slides: We will break down each aspect of the GCS (EVM) and then, using and example, calculate a patients GCS and RTS.When documenting GCS in the narrative, it is important to break down the scores for each of the three parameters and also provide the total score. Using the example above, one would document: GCS: 3-4-4=11. This paints a much clearer picture than simply documenting GCS 11, which does not indicate which part of the GCS the patient lost points on for inappropriate responses. This also allows for much better trending of the patients responses over time.

**Some would argue this is a localizes response to pain, rather than a withdrawsA true localizes, or higher level response, would be to use her other arm to try to remove the painful stimulus (your hand starting the IV)Can consider a BREAK hereWe want to know if what we are doing works (Evidence Based Medicine), NOT because that is the way we have always done it.These are the 17 Key Data Fields emphasized in this presentation.The data in the above study were based on 96,763 total EMS calls, 32.4% of which were trauma calls. The study of 17 key trauma fields on the PCR found compliance in trauma documentation on PCRs submitted to the BEMS ranged from 0-92.8%.On scene time was reported with the most regularity (92.8% of the time).Temperature was one of the variables that was not reported in any of the PCRs reviewed. Temperature is an important vital sign because many studies have shown increased death and disability if trauma patients are allowed to get hypothermic.