and Accident Auditing

Dr. Mohammad Hassan Naseri, MD.Associate Professor of Cardiovascular SurgeryBaghiyatallah Medical Sciences University,Truama Research CenterWinter, 2009

To get the right patient To get the right patient to the right hospital to the right hospital

at the right time.at the right time.

Leading cause of death in people age 1-34◦ #1: MVCs◦ #2: Firearms◦ #3: Falls

5th leading cause of death overall◦ 1/3 intentional◦ 2/3 unintentional

Someone in NH dies of trauma every 20 hours

05101520253035404550

Immediate Early Late

% of Deaths

Severe Head or CV Injury

Major Torso or Head Injury

Infection and MSOF

Injury PreventionSystem PlanningEvaluation & MonitoringCommunication / Collaboration / Teamwork

Prevention & Public Education Hospitals & EMS Providers Medical Direction: On-line & Standing Orders Triage & Transport Guidelines Rehabilitation Evaluation

Hospital AssessmentTrauma Triage GuidelinesCommunication GuidelinesTransport GuidelinesResources available to you

Performance Levels◦Initial, Advanced, or Leadership

Roles◦Area or Regional

Capability Levels◦Adult & Pediatric; Level I, II, or III

Hospital Staff Self-AssessmentSite Visit by Members of TMRC

◦Confirmation ◦Consultative / Assistance

Use Pathway Card to determine Pt Status Trauma Triage Communication

◦ Contact Medical Control◦ Relay enough info to aid in decision making

Transport Decision → Transport

Motorcycle v. Pickup Truck Truck traveling 40 mph, ? Cycle speed 30 y/o male thrown 20 feet Truck has damage Rider’s helmet has few, minor scratches

What does this information provide us?

What additional information do you need?

Airway is open and clear Opens eyes to loud verbal stimuli Localizes painful stimuli Confused verbal response to questions RR=32, ≠ chest expansion, R. wall bruising Strong radial pulses, no major bleeding Skin pale, moist, cool

Can you estimate GCS & RTS?

What is the Patient Status?

No obvious head injury, PERRLA No JVD or tracheal tugging, C-spine non-

tender ≠ Chest expansion, crepitus, lung sounds R. Abdomen soft, but guarding; pelvis stable Open L. femur fracture Abrasions and small laceration on R. arm Pulse = 100, BP 110/68, RR = 32 Medic alert tag for Coumadin use

Confirm or dispute your initial severity determination.

What pertinent information will you communicate to medical control?

“MIVT”

Injury Severity Hospital capability, location, driving

time Area Level III Trauma Hospital is 10 minutes Regional Level II Hospital is 20 minutes

ALS intercept is unavailable Helicopter is available and ETA to

scene is 20 minutesWhat decision will Medical Control make?

Why?

Complete a PCR for every call and every pt This includes when care or transport was:

◦ Requested◦ Rendered◦ Refused◦ Cancelled

This includes pts treated by one agency and transported by another. >1 PCR may be

generated for the same pt/pt encounter.

A written PCR is:◦ Complete◦ Accurate◦ Legible◦ Professional

Be:◦ Objective◦ Brief◦ Accurate◦ Clear

Legible Handwriting & Correct Grammar and Spelling are a must!

“Poor documentation = Poor care”

DO NOT use “white out” or any correction fluid/tape

DO NOT try to obliterate or destroy information◦ It 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 documentation

DO NOT leave blank or empty lines or spaces!

Who started care before you arrived How you found the patient Anything you found during your assessment

◦ Pertinent (+) and (-) findings Anything you did for the patient & their

response Where you left the patient (& with whom) Report given (to whom) & questions

answered Condition of the patient upon termination of

care◦ PIVs patent? MAE=x4? ETT position verified?If you did it, you should write it (& vice versa)

““Within Normal Limits”Within Normal Limits”OrOr

““We Never Looked”We Never Looked”??????????????

Any foul or objectionable language Anything that could be considered as libel

◦ Example: “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

Patients ABLE to refuse care include:◦ Competent individuals – defined as the ability

to understand the nature and consequences of their actions AND

◦ Adult – defined as 18 years of age or older, except: An emancipated minor A married minor A minor in the military

Patients 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 signs Mental retardation and/or deficiency Any patient who makes clearly irrational decisions in the

presence of an obvious potentially life or limb threatening injury, including persons who are emotionally unstable

Any 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 circumstances

Under age 18 (except as denoted above)

Perform a complete exam with vitals◦ If refused, document this

Determine if the patient is competent to refuse

Ensure the pt or responsible party:◦ Has been told of his/her condition◦ Understands the risks or refusal◦ Assumes all risk & releases EMS from liability◦ Understands he/she can call you back

anytime

Any information you are able to elicit while taking the patient’s history:◦ Chief Complaint (CC)◦ History of Present Illness (HPI)

“OPQRST – AS/PN”◦ Past Medical & Surgical History◦ Meds and Allergies

General Impression Primary Assessment

◦ ABCDE Secondary Assessment

◦ Head to Toe Exam

Field Diagnosis What you believe the problem to be

◦ Working diagnosis◦ Example: “Chest pain, R/O MI”; “closed head

injury with altered LOC”; “pelvic fracture”

Treatment Patient Response 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.”

Chief Complaint History Assessment Rx Transport

Benefit patient care Provide feedback to the EMS agency/provider Evaluate system performance Determine if the patient treatment protocols

are working for the patient population served Design injury prevention programs Perform quality assurance Outline opportunities for improvement in data

collection and the reporting system

Response time Performance, such as ETI success rates Procedures, such as number of IVs per

provider per year Number of CPR calls

“Garbage in…garbage out.”

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

On Scene Pt Status Pulse Resp Rate Systolic BP GCS Total GCS Eye GCS Motor GCS Verbal

Diastolic BP RTS Total RTS GCS RTS Resp Rate RTS BP Trauma Patient? Temperature Trauma Team

Activated?