1. Emergency Department Trauma Flowsheet Documentation Evelyn Clark-Kula, RN, BSN, Janice Gillespie, RN, Bridget Gaughan, RN, MSN, Sylvia Wright, RN, MSN, Kristi Dombrow, RN, BSN, and Karen Steed, RN, BSN Confidential: For Quality Improvement Purposes Only

2. Project Aim Statement The Trauma QI Committee identified that certain key indicators were not consistently being documented on the trauma flowsheets. The aim of this project was to increase compliance by the Emergency Department nurses in documenting these indicators. Confidential: For Quality Improvement Purposes Only

3. Measurement Goal All indicators >80% compliance per ACS (American College of Surgeons) criteria by February 1, 2008 Confidential: For Quality Improvement Purposes Only

4. Solutions Implemented Monthly Trauma QI attendance at ED Clinical Operations Committee Meetings Letters written to ED RNs who did not meet documentation indicators beginning 8/1/07 Distribution of letters to ED Staff by ED Management Team Education of ED staff by ED Educator and ED Management Team Informal real-time chart review amongst fellow ED RNs and Management Team Trauma Program Manager review of real-time trauma resuscitation documentation Posting of flowsheet indicators on bedside tables in ED Trauma Bay Confidential: For Quality Improvement Purposes Only

5. Sample ED RN Letter Confidential-Quality Improvement Material Loyola University Medical Center Trauma Services Emergency Department RN Documentation MR# 0000000 Smith, John To: Debbie Reynolds, RN From: Jan Gillespie, RN Trauma Program Manager Trauma QI Committee Debbie, on 8/1/07 you helped care for the above mentioned patient. On the trauma flowsheet you documented when the Trauma Attending was called and when they answered, but not if they arrived or the time of their arrival – you left that space blank. If they do not arrive in the trauma bay a (-) should be placed in the arrival box – otherwise a time must be written when they arrive. To chart that the trauma team was present is not sufficient. In addition, the patient’s Intake & Output were not documented at the time of disposition. This is for educational purposes and trending. If you have any questions please call me at x73715, page me at 15768, or email me. On a positive note, you did chart the pt time of arrival in the box correctly, and the patient’s temperature. Attached please find a copy of the above mentioned flowsheet. Confidential: For Quality Improvement Purposes Only

6. Results All indicators reached >80% goal in February of 2008 as reported at ED Clinical Operations Committee Meeting Confidential: For Quality Improvement Purposes Only

7. Percent of charts with documentation of trauma attending arrival Documentation of Trauma Attending Arrival Month May 2007 June 2007 July 2007 August 2007 September 2007 October 2007 November 2007 December 2007 January 2008 February 2008 March 2008 40 50 60 70 80 90 100 Letters to staff initiated Mean = 77.55 Confidential: For Quality Improvement Purposes Only

8. Letters to staff initiated Mean = 96.47 Confidential: For Quality Improvement Purposes Only

9. Letters to staff initiated Confidential: For Quality Improvement Purposes Only

10. Letters to staff initiated Confidential: For Quality Improvement Purposes Only

11. Mean = 93.22 Letters to staff initiated Confidential: For Quality Improvement Purposes Only

12. Analysis Improved documentation of Trauma Attending Arrival, Patient Arrival, Temperature, and Intake/Output to greater than >80% goal Greatest improvement was noticed after letters were sent to ED RNs Confidential: For Quality Improvement Purposes Only

13. Next Steps Education of ED staff will remain continuous due to turnover of staff credentialed to care for trauma patients In past years, decreased emphasis on documentation has resulted in poor compliance with specific indicators Confidential: For Quality Improvement Purposes Only