Trauma Registry Documentation December 16, 2014

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Marsha Golden
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Trauma Registry Documentation December 16, 2014 The State of Florida now

Alerts are not called, patients treated with trauma related injuries meet

1 Trauma Registry Documentation December 16, 2014 The State of Florida now requires ALL Acute Care hospitals to submit data to the statetrauma Registry. Although Baptist Health hospitals are NOT Trauma Centers and Trauma Alerts are not called, patients treated with trauma related injuries meet the Florida trauma alert criteria requiring the Trauma Registry form to be completed. Two questions in required fields have been added to the Adult and Peds ED Triage Forms. Right click on the reference text (REF) icon to see the list of qualifying injuries or the list of trauma alert criteria. Answering Yes to either question causes the Trauma Registry Icon to appear on the tracker board and the trauma registry form must be completed. 1

2 Adult and Pediatric Patient Qualifying Injuries per State Data Trauma Inclusion Criteria (Reference Data) Fracture Of Skull Fracture Of Spine And Trunk Fracture Of Upper Limb Fracture Of Lower Limb Dislocation Sprains And Strains Of Joints And Adjacent Muscles Intracranial Injury, Excluding Those With Skull Fracture Internal Injury Of Chest, Abdomen, And Pelvis Open Wound Of Head, Neck, And Trunk Open Wound Of Upper Limb QUALIFYING INJURIES Open Wound Of Lower Limb Injury To Blood Vessels Late Effects Of Injuries, Poisonings, Toxic Effects, And Other External Causes Superficial Injury Contusion With Intact Skin Surface Crushing Injury Effects Of Foreign Body Entering Through Orifice Burns Injury To Nerves And Spinal Cord Certain Traumatic Complications And Unspecified Injuries 2

3 Adult Patient Trauma Alert Criteria (Reference Data) Adult Trauma Criteria - RED INJURY CAUSED BY TRAUMA THAT RESULTS IN ONE OF THE FOLLOWING: Circulation: Systolic B/P less than 90mmHg Adult Trauma Criteria - BLUE INJURY CAUSED BY TRAUMA THAT RESULTS IN TWO OF THE FOLLOWING: Respiratory rate of 30 or greater Circulation: lack of radial pulse with HR greater than 120 HR greater than 120 Airway control greater than administration of O2 Paralysis Major degloving injury Major flap avulsion of greater than 5 inches Best Motor Response (BMR) Component of GCS with score of 4 or less Best Motor Response (BMR) Component of GCS with score of 5 Suspicion of spinal cord injury Loss of sensation Amputation proximal to wrist or ankle Penetrating injury to head, neck or torso Signs and symptoms of 2 or more leg fractures Gun shot wound to extremities Signs and symptoms of single long bone fracture from MVC Signs and symptoms of single long bone fracture from fall of 10ft or greater Age 55 or older Ejection from motor vehicle 2 nd or 3 rd degree burns to 15% or greater Total Body Surface Area (TBSA) Driver impact steering wheel with deformity Pediatric Patient Trauma Alert Criteria Peds Trauma Criteria - RED Peds Trauma Criteria - BLUE INJURY CAUSED BY TRAUMA THAT RESULTS IN ONE OF THE FOLLOWING: Airway: Intubated/maintained by adjuncts Altered Mental Status Comatose Paralysis Suspicion of spinal cord injury Loss of sensation Faint or non-palpable carotid or femoral pulse INJURY CAUSED BY TRAUMA THAT RESULTS IN TWO OF THE FOLLOWING: Symptoms of amnesia Loss of consciousness Radial or pedal pulses absent with carotid/pedal present Systolic B/P less than 90 mmhg Signs and symptoms of single long bone fracture Weight 11kg or less Pediatric length 33 inches or less Systolic B/P less than 50 mmhg Evidence of long bone fracture Multiple fracture sites Major soft tissue injury Major degloving Major flap avulsion 2nd or 3rd degree burns to 15% or greater Total Body Surface Area (TBSA) Penetrating injury to head, neck or torso 3 Amputation proximal to wrist or ankle

Completing the Trauma Registry Form The nurse caring for the patient clicks on the Trauma Registry Icon on the tracker and completes the Trauma Registry Form.

GCS MUST BE COMPLETED ON ALL PATIENTS WHO MEET TRAUMA CRITERIA Valid GCS indicates GCS was assessed on admission and the patient was not sedated, not intubated, and did not have obstruction to the

4 Completing the Trauma Registry Form The nurse caring for the patient clicks on the Trauma Registry Icon on the tracker and completes the Trauma Registry Form. *Note: Form data can be retrieved from the EMS run sheet or by interviewing the patient. GCS MUST BE COMPLETED ON ALL PATIENTS WHO MEET TRAUMA CRITERIA Valid GCS indicates GCS was assessed on admission and the patient was not sedated, not intubated, and did not have obstruction to the eye. GCS is documented in IView. *If Valid GCS is chosen then the bottom three options cannot be selected. TRAUMA ALERT TYPE This answer will be NTA (not a trauma alert) the majority of the time. This field is asking if EMS called a Trauma alert or if the hospital called a trauma alert. (Baptist does not call Trauma alerts and is not a Trauma center. 4

5 Transport Mode: If any ambulance option is selected, the EMS fields will open. Inter-Facility Transfer: Answering YES opens the Referring Hospital Arrival/Discharge Date/time fields. Inter-Facility Transfer includes transfers from Clay to Downtown, Downtown to Memorial, Orange Park to Baptist, etc. 5

6 Trauma Registry Documentation December 16, 2014 All documentation flows to Results Review Care Team Doc Trauma Registry Information A Trauma Registry Reminder will be added to the Depart Process. Click on notepad next Trauma Registry Reminder to open the form. The form will contain the previously documented information so that the nurse does not have to re-document. 6

Assessment and Scoring Tools

Assessment and Scoring Tools 2013 APGAR Scale 0 points 1 point 2 points Heart Rate Absent 100 Respiratory Rate Absent Slow, irregular Good, drying Irritability Flaccid Some flexion Active motion