Improved Compliance With Quality Assurance Markers During Trauma Room Resuscitation Using Trauma Nurse Specialists JEFFREY HAMMOND,
Trauma nurse specialists (TNS) have been shown to reduce the burden on house staff and to facilitate patient care on trauma wards. In the authors’ facility, this expertise has been extended to the emergency department where TNS contribute to an improved standard of care by (1) nursing assessment and injury recognition and (2) continuity of care. As specially trained individuals, TNS expand upon the mie 01the emergency department staff nurse. The TNS could be shown to improve compliance with trauma resuscitation room protocol and quality assurance markers of direct patient management at a statistically significant level. (Am J Emerg Med 1992;10:323-325. Copyright 0 1992 by W.9. Saunders Company)
MD,* JEANNE ECKES, RN,t ADELE WELCOM, RN*
At the University of Miami/Jackson Memorial Medical Center, (Miami, FL), this expertise has been extended to the emergency department, where TNS contribute to an improved standard of care by (I) providing nursing assessment aimed at injury recognition and (2) establishing a continuity of care. As a means to justify the added personnel expense for TNS, selective quality assurance markers were retrospectively reviewed before and after the institution of the program to use TNS to determine if improved compliance with trauma resuscitation room protocols resulted. METHODS
While trauma nursing has a long history over the past century in a military setting, “trauma nurses” in a civilian population are a relatively new phenomenon. Civilian trauma nursing was born in 1961 at the University of Maryland in a two-bed research unit.’ Eventually, trauma nursing moved out of the intensive care unit into the emergency department, operating room, and surgical wards. The trauma nurse coordinator is now a fixture of any organized and systemic approach to trauma care. An extension of the trauma nurse coordinator concept is the trauma nurse specialist (TNS). Like the trauma nurse coordinator, the TNS (or sometimes called trauma nurse practitioner) should be able to demonstrate expert knowledge and skills in the practice of trauma nursing, contribute to the development and implementation of nursing standards for trauma patients and their families, and collaborate with protocols and research. Moreover, the TNS provides a continuity of care, avoiding fragmentation of record-keeping, while also alleviating the burden on staff nurses who might otherwise be pulled from other responsibilities.* Trauma nurse specialists have been shown to reduce the burden on surgical house staff, and to facilitate patient care on surgical wards and in trauma outpatient clinic settings.3
From ‘University of Medicine and Dentistry of New JerseyRobert Wood Johnson Medical School, New Brunswick, NJ; the TDivision of Trauma Services, University of Miami/Jackson Memorial Medical Center; and $Jackson Memorial Hospital, Miami, FL. Manuscript received September 23, 1991; revision accepted January 8, 1992. Presented in part as an abstract to the Annual meeting of the American Trauma Society, Washington, DC, May 1991. Address reprint requests to Dr Hammond, Associate Professor of Surgery, University of Medicine and Dentistry of New JerseyRobert Wood Johnson Medical School, One Robert Wood Johnson Place, CN19, New Brunswick, NJ 08903-0019. Key Words: Trauma nurse, documentation, quality assurance. Copyright 0 1992 by W.B. Saunders Company. 0735-6757/92/l 004.0011$5.00/O
Our facility is a level I trauma center treating over 3,000 patients per year. The emergency department, the most active in the southeastern United States, is divided into separate sections for surgery, medicine, pediatrics, obstetrics/ gynecology, and psychiatry. Within the surgical emergency department, a separate pathway exists for admission and treatment of patients meeting preselected criteria for “major” trauma. For each 12-hour nursing shift, two TNS, who have undergone a 3-week orientation and B-week preceptorship, are present to assist in trauma resuscitation. The TNS position requires a registered nurse to be Advanced Cardiac Life Support/Pediatric Advanced Life Support-certified and to have audited an Advanced Trauma Life Support course. They have no specific assignment but trauma, although they will assist with the general function of the surgical emergency department during “down time”. Their specific job description includes making the trauma room ready, preparation for an injured patient, participating as a member of the flight response team, and assisting the physicians once the patient arrives. They obtain baseline vital signs, perform an independent nursing assessment of the patient, and make sure appropriate laboratory studies are sent. They accompany the patient during transport to radiology, stay with that patient until final disposition to the operating room or intensive care unit, and assist in family counseling. Finally, the TNS is required to participate in trauma education by providing in-service and outreach presentations. The annual salary range for TNS was $30,000 to $40,000, compatible with that of equally senior nurses. Performance of the TNS was evaluated through a retrospective quality assurance (QA) review. This was developed as an extension of already existing nursing QA programs in the emergency department. Twenty items were reviewed as QA markers relative to trauma room resuscitation. Eighty emergency department trauma room resuscitation records were randomly selected for the period January 323
324
AMERICAN
through April 1987 (20 per month), tution of the TNS program. Eighty randomly selected from a similar during which the TNS program had 2 years. Results were analyzed by
JOURNAL
a period predating additional records 4-month period in been in place longer Student’s t-test.
instiwere 1990 than
OF EMERGENCY
MEDICINE
H Volume
10, Number
4 n July 1992
K compliance
1
RESULTS Of the 20 markers, four directly involved nursing assessment of patient injuries comparable to a secondary or tertiary survey, three identified injury scoring mechanism, seven evaluated other direct patient care items, and six assessed nursing administrative items. Based on standard approaches to QA, 80% compliance was considered satisfactory. Nursing assessment of neurologic, thoracic, and abdominal status all dramatically improved from less than 65% to greater than 80% (Figure 1). Although below acceptable QA standards, nursing assessment in musculoskeletal status was also statistically significantly improved, increasing from 38% to 66%. Injury scoring went from absent for the Glascow coma scale and infrequent for the trauma score to 93% and 86%, respectively. Nursing identification of patient diagnosis, and recording of x-rays obtained and procedures performed improved dramatically, and exceeded 84% compliance (Figure 2). Full compliance was obtained from recording vital signs every 15 minutes in unstable patients compared with 60% when staff emergency department nurses were used for trauma resuscitation. Improvement was also noted in recording the dose and route of drug administration (80% pre-TNS, 98% postTNS). Documentation of nonpatient care-related, but important, data, such as rescue alarm number, date and time of arrival, intravenous catheter location, and patient disposition by time and location, all improved (Figure 3). DISCUSSION As specially trained individuals, TNS expand upon the role of the emergency department staff nurse. This study demonstrates the value of such a program in documentation of and assistance in patient care. In so doing, it complements the work of Spisso and associates3 who demonstrated that TNS on surgical wards dramatically increase documentation in the inpatient and outpatient setting. In their study, the description of inpatient injuries and procedures improved from 78% and 74%, respectively, when done by surgical
100,
%compliance
Impact
FIGURE 2. TNS.
Xraya
procedurea
diagnoaia
mad data
Impact of TNS patient care. n , Pre-TNS; I, post-
house officers, to 98% and 97% when performed by TNS. Review of systems in outpatients increased from 55% to 94% for an examination of the extremities and 60% to 100% for an abdominal exam. The value of such assessment and documentation cannot be underestimated either from the aspect of patient care or financial consideration. Such assessment in effect becomes a “tertiary” trauma survey which contributes to a decrease in the rate of missed injuries. Enderson and colleagues at the University of Tennessee at Knoxville identified a 9% missed injury rate in 399 patients; 57% of these were musculoskeleta1 injuries.4 As demonstrated in our study, evaluation of the musculoskeletal system is the most frequently undocumented assessment. The use of TNS may contribute to a decrease in such missed injuries. The financial impact of missed injuries results in increased QA expenses. Rhodes and associates in Allentown, PA estimated the cost of analysis as $11,000 for chart reviews of just 332 incidents flagged by eight American College of Surgeons Committee on Trauma filters.5 Quality assurance reviews fall into three broad categories: input, process, and outcome.6 “Input” catalogues resources and services. such as the availability of surgeons. “Process” reflects the application of such resources to demands, for example, ambulance run times. Finally, “outcome” addressed the final status of the patients treated. The QA markers used in our study evaluate performance (input) and appropriateness (process) but do not evaluate the interventions in terms of their effect on outcome. Unfortunately, such a relationship is not always clear-cut. 9; comdianca
abdoman
chaat
FIGURE 1. post-TNS.
VSqlSmin
of TNS
nursing
assessment.
Who
4,
Pre-TNS; B,
dawtlma
FIGURE 3. post-TNS.
EMS
data
IV data
Impact of TNS administrative
dfapoUticn
data. a,
Pre-TNS;
HAMMOND ET AL n TRAUMA NURSE SPECIALISTS AND CIA
Nevertheless, the importance of management of data, especially in the trauma arena, is clear. The use of trauma flow sheets to enhance the organized approach to data collection through a formalization of the process only marginally improves the medical record. Walters and McNeil developed and used five separate physician-oriented two-page forms for trauma resuscitation recording in Toronto, Canada.7 While in general they demonstrated improvement in recording information on date, time, general neurologic status, and airway, they showed no improvement in assessment of the abdomen, spinal injury, trauma history, or recording of x-ray results. In our opinion, while flow sheets may facilitate the process, it is not the paperwork but the personnel that is important. The TNS directs the nursing care of the critically injured patient, coordinates patient care with the physician, and follows the patient from emergency department arrival until disposition to the operating room, intensive care unit, or surgical ward. By initiating the nursing history and assessment, particular emphasis on identification of subtle lesions is enhanced and priorities in the planning of patient care clarified. Since documentation practices are used as an
325
indirect measure of patient care, one can infer that the presence of the TNS in the trauma resuscitation room contributes to improved patient management. REFERENCES 1. Beachley M, Snow S, Trimble P: Developing trauma care systems: The trauma nurse coordinator. J Nurs Adm 1988;18:3442 2. Songne EA, Holmquist P: Comprehensive care by trauma nurse providers: Mission Hospital’s ten-year experience. J Emerg Nurs 1991;17:73-79 3. Spisso J, O’Callaghan C, McKennan M, et al: Improved quality of care and reduction of housestaff workload using trauma nurse practitioners. J Trauma 1990;30:660-665 4. Enderson B, Reath 0, Meadors J, et al: The tertiary trauma survey: A prospective study of missed injury. J Trauma 1990;30: 666-70 5. Rhodes M, Sacco W, Smith S, et al: Cost effectiveness of trauma quality assurance audit filters. J Trauma 1990;30:724-727 6. Nakayama D, Sartz E, Gardner M, et al: Quality assessment in the pediatric trauma care system. J Pediatr Surg 1989; 24:159-62 7. Walters B, McNeil1 I: Improving the record of patient assessment in the trauma room. J Trauma 1990;30:398-409
Trauma nurse specialists (TNS) have been shown to reduce the burden on house staff and to facilitate patient care on trauma wards. In the authors’ facility, this expertise has been extended to the emergency department where TNS contribute to an improved standard of care by (1) nursing assessment and injury recognition and (2) continuity of care. As specially trained individuals, TNS expand upon the mie 01the emergency department staff nurse. The TNS could be shown to improve compliance with trauma resuscitation room protocol and quality assurance markers of direct patient management at a statistically significant level. (Am J Emerg Med 1992;10:323-325. Copyright 0 1992 by W.9. Saunders Company)
MD,* JEANNE ECKES, RN,t ADELE WELCOM, RN*
At the University of Miami/Jackson Memorial Medical Center, (Miami, FL), this expertise has been extended to the emergency department, where TNS contribute to an improved standard of care by (I) providing nursing assessment aimed at injury recognition and (2) establishing a continuity of care. As a means to justify the added personnel expense for TNS, selective quality assurance markers were retrospectively reviewed before and after the institution of the program to use TNS to determine if improved compliance with trauma resuscitation room protocols resulted. METHODS
While trauma nursing has a long history over the past century in a military setting, “trauma nurses” in a civilian population are a relatively new phenomenon. Civilian trauma nursing was born in 1961 at the University of Maryland in a two-bed research unit.’ Eventually, trauma nursing moved out of the intensive care unit into the emergency department, operating room, and surgical wards. The trauma nurse coordinator is now a fixture of any organized and systemic approach to trauma care. An extension of the trauma nurse coordinator concept is the trauma nurse specialist (TNS). Like the trauma nurse coordinator, the TNS (or sometimes called trauma nurse practitioner) should be able to demonstrate expert knowledge and skills in the practice of trauma nursing, contribute to the development and implementation of nursing standards for trauma patients and their families, and collaborate with protocols and research. Moreover, the TNS provides a continuity of care, avoiding fragmentation of record-keeping, while also alleviating the burden on staff nurses who might otherwise be pulled from other responsibilities.* Trauma nurse specialists have been shown to reduce the burden on surgical house staff, and to facilitate patient care on surgical wards and in trauma outpatient clinic settings.3
From ‘University of Medicine and Dentistry of New JerseyRobert Wood Johnson Medical School, New Brunswick, NJ; the TDivision of Trauma Services, University of Miami/Jackson Memorial Medical Center; and $Jackson Memorial Hospital, Miami, FL. Manuscript received September 23, 1991; revision accepted January 8, 1992. Presented in part as an abstract to the Annual meeting of the American Trauma Society, Washington, DC, May 1991. Address reprint requests to Dr Hammond, Associate Professor of Surgery, University of Medicine and Dentistry of New JerseyRobert Wood Johnson Medical School, One Robert Wood Johnson Place, CN19, New Brunswick, NJ 08903-0019. Key Words: Trauma nurse, documentation, quality assurance. Copyright 0 1992 by W.B. Saunders Company. 0735-6757/92/l 004.0011$5.00/O
Our facility is a level I trauma center treating over 3,000 patients per year. The emergency department, the most active in the southeastern United States, is divided into separate sections for surgery, medicine, pediatrics, obstetrics/ gynecology, and psychiatry. Within the surgical emergency department, a separate pathway exists for admission and treatment of patients meeting preselected criteria for “major” trauma. For each 12-hour nursing shift, two TNS, who have undergone a 3-week orientation and B-week preceptorship, are present to assist in trauma resuscitation. The TNS position requires a registered nurse to be Advanced Cardiac Life Support/Pediatric Advanced Life Support-certified and to have audited an Advanced Trauma Life Support course. They have no specific assignment but trauma, although they will assist with the general function of the surgical emergency department during “down time”. Their specific job description includes making the trauma room ready, preparation for an injured patient, participating as a member of the flight response team, and assisting the physicians once the patient arrives. They obtain baseline vital signs, perform an independent nursing assessment of the patient, and make sure appropriate laboratory studies are sent. They accompany the patient during transport to radiology, stay with that patient until final disposition to the operating room or intensive care unit, and assist in family counseling. Finally, the TNS is required to participate in trauma education by providing in-service and outreach presentations. The annual salary range for TNS was $30,000 to $40,000, compatible with that of equally senior nurses. Performance of the TNS was evaluated through a retrospective quality assurance (QA) review. This was developed as an extension of already existing nursing QA programs in the emergency department. Twenty items were reviewed as QA markers relative to trauma room resuscitation. Eighty emergency department trauma room resuscitation records were randomly selected for the period January 323
324
AMERICAN
through April 1987 (20 per month), tution of the TNS program. Eighty randomly selected from a similar during which the TNS program had 2 years. Results were analyzed by
JOURNAL
a period predating additional records 4-month period in been in place longer Student’s t-test.
instiwere 1990 than
OF EMERGENCY
MEDICINE
H Volume
10, Number
4 n July 1992
K compliance
1
RESULTS Of the 20 markers, four directly involved nursing assessment of patient injuries comparable to a secondary or tertiary survey, three identified injury scoring mechanism, seven evaluated other direct patient care items, and six assessed nursing administrative items. Based on standard approaches to QA, 80% compliance was considered satisfactory. Nursing assessment of neurologic, thoracic, and abdominal status all dramatically improved from less than 65% to greater than 80% (Figure 1). Although below acceptable QA standards, nursing assessment in musculoskeletal status was also statistically significantly improved, increasing from 38% to 66%. Injury scoring went from absent for the Glascow coma scale and infrequent for the trauma score to 93% and 86%, respectively. Nursing identification of patient diagnosis, and recording of x-rays obtained and procedures performed improved dramatically, and exceeded 84% compliance (Figure 2). Full compliance was obtained from recording vital signs every 15 minutes in unstable patients compared with 60% when staff emergency department nurses were used for trauma resuscitation. Improvement was also noted in recording the dose and route of drug administration (80% pre-TNS, 98% postTNS). Documentation of nonpatient care-related, but important, data, such as rescue alarm number, date and time of arrival, intravenous catheter location, and patient disposition by time and location, all improved (Figure 3). DISCUSSION As specially trained individuals, TNS expand upon the role of the emergency department staff nurse. This study demonstrates the value of such a program in documentation of and assistance in patient care. In so doing, it complements the work of Spisso and associates3 who demonstrated that TNS on surgical wards dramatically increase documentation in the inpatient and outpatient setting. In their study, the description of inpatient injuries and procedures improved from 78% and 74%, respectively, when done by surgical
100,
%compliance
Impact
FIGURE 2. TNS.
Xraya
procedurea
diagnoaia
mad data
Impact of TNS patient care. n , Pre-TNS; I, post-
house officers, to 98% and 97% when performed by TNS. Review of systems in outpatients increased from 55% to 94% for an examination of the extremities and 60% to 100% for an abdominal exam. The value of such assessment and documentation cannot be underestimated either from the aspect of patient care or financial consideration. Such assessment in effect becomes a “tertiary” trauma survey which contributes to a decrease in the rate of missed injuries. Enderson and colleagues at the University of Tennessee at Knoxville identified a 9% missed injury rate in 399 patients; 57% of these were musculoskeleta1 injuries.4 As demonstrated in our study, evaluation of the musculoskeletal system is the most frequently undocumented assessment. The use of TNS may contribute to a decrease in such missed injuries. The financial impact of missed injuries results in increased QA expenses. Rhodes and associates in Allentown, PA estimated the cost of analysis as $11,000 for chart reviews of just 332 incidents flagged by eight American College of Surgeons Committee on Trauma filters.5 Quality assurance reviews fall into three broad categories: input, process, and outcome.6 “Input” catalogues resources and services. such as the availability of surgeons. “Process” reflects the application of such resources to demands, for example, ambulance run times. Finally, “outcome” addressed the final status of the patients treated. The QA markers used in our study evaluate performance (input) and appropriateness (process) but do not evaluate the interventions in terms of their effect on outcome. Unfortunately, such a relationship is not always clear-cut. 9; comdianca
abdoman
chaat
FIGURE 1. post-TNS.
VSqlSmin
of TNS
nursing
assessment.
Who
4,
Pre-TNS; B,
dawtlma
FIGURE 3. post-TNS.
EMS
data
IV data
Impact of TNS administrative
dfapoUticn
data. a,
Pre-TNS;
HAMMOND ET AL n TRAUMA NURSE SPECIALISTS AND CIA
Nevertheless, the importance of management of data, especially in the trauma arena, is clear. The use of trauma flow sheets to enhance the organized approach to data collection through a formalization of the process only marginally improves the medical record. Walters and McNeil developed and used five separate physician-oriented two-page forms for trauma resuscitation recording in Toronto, Canada.7 While in general they demonstrated improvement in recording information on date, time, general neurologic status, and airway, they showed no improvement in assessment of the abdomen, spinal injury, trauma history, or recording of x-ray results. In our opinion, while flow sheets may facilitate the process, it is not the paperwork but the personnel that is important. The TNS directs the nursing care of the critically injured patient, coordinates patient care with the physician, and follows the patient from emergency department arrival until disposition to the operating room, intensive care unit, or surgical ward. By initiating the nursing history and assessment, particular emphasis on identification of subtle lesions is enhanced and priorities in the planning of patient care clarified. Since documentation practices are used as an
325
indirect measure of patient care, one can infer that the presence of the TNS in the trauma resuscitation room contributes to improved patient management. REFERENCES 1. Beachley M, Snow S, Trimble P: Developing trauma care systems: The trauma nurse coordinator. J Nurs Adm 1988;18:3442 2. Songne EA, Holmquist P: Comprehensive care by trauma nurse providers: Mission Hospital’s ten-year experience. J Emerg Nurs 1991;17:73-79 3. Spisso J, O’Callaghan C, McKennan M, et al: Improved quality of care and reduction of housestaff workload using trauma nurse practitioners. J Trauma 1990;30:660-665 4. Enderson B, Reath 0, Meadors J, et al: The tertiary trauma survey: A prospective study of missed injury. J Trauma 1990;30: 666-70 5. Rhodes M, Sacco W, Smith S, et al: Cost effectiveness of trauma quality assurance audit filters. J Trauma 1990;30:724-727 6. Nakayama D, Sartz E, Gardner M, et al: Quality assessment in the pediatric trauma care system. J Pediatr Surg 1989; 24:159-62 7. Walters B, McNeil1 I: Improving the record of patient assessment in the trauma room. J Trauma 1990;30:398-409
