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National Clinical Guideline Centre (UK). Major Trauma: Assessment and Initial Management. London: National Institute for Health and Care Excellence (NICE); 2016 Feb. (NICE Guideline, No. 39.)

Major Trauma: Assessment and Initial Management.

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15Documentation

15.1. Introduction

Currently, different pre-hospital and hospital service providers use different methods of documentation but standardisation may improve patient outcomes and reduce resource use. Standardisation includes both what is information is documented and in what format it used.

15.2. Review question: Is documentation using a standard form across all clinical settings (pre-hospital and hospital) in which a major trauma patient might be treated clinically and cost effective?

For full details see review protocol in Appendix C.

Table 135PICO characteristics of review question

Population	Children, young people and adults who have experienced a traumatic incident.
Intervention(s)	Standard documentation across all clinical settings, including proforma, electronic medical records
Comparison(s)	Varying documentation
Outcomes	Critical: Mortality at 24 hours Mortality at 30 days/1 month Mortality at 12 months Health-related quality of life Complications Important: Length of stay Patient-reported outcome: return to normal activities Patient-reported outcome: psychological wellbeing. Missing data Timing of transfers
Study design	RCT, cohort, observational

15.3. Clinical evidence

Five retrospective cohort studies⁷⁸^,⁷⁹^;¹¹¹^,¹¹²^;³⁴^,³⁴^;¹²⁶^,¹²⁶^;⁹⁴^,⁹⁴ were identified that looked at standardisation documentation across settings. One study implemented a checklist and four electronic medical records.

Table 136

Summary of studies included in the review.

Table 137

Clinical evidence summary: checklist versus no checklist.

Table 138

Clinical evidence summary table: electronic medical record versus no electronic medical record.

Narrative review

Table 139Checklist versus no checklist

Outcome	Median (IQR if reported), p
ICU days	2 versus 1, p=0.007
Hospital length of stay	2 (1 to 5) versus 2 (1 to 4), p=0.000
Hospital length of stay (ISS >16)	5 versus 3, p=0.021

Electronic medical records versus no electronic medical record

One study ¹¹¹^,¹¹² reported the following user feedback:

Table 140User feedback

Use of service	Feedback
Organisation and time efficiency of post-take ward	30/32 (94%) helpful
Organisation and time efficiency of morning trauma meetings	31/21 (97%) helpful
Quality of information passed on at handover	27/28 (96%) improved quality
Communication of information amongst trauma team (including allied staff)	28/36 (78%) improved communication
Impact of working day time management	22/32 (69%) saved time
Impact on patient management	26/34 (76%) positive
Overall satisfaction	32/43 (94%)

One study ¹²⁶^,¹²⁶ reported the following outcomes:

Table 141Outcomes

Outcomes	No electronic medical record	Electronic medical record	p value
Hospital length of stay (days)	7.9	7.1	0.02
ICU length of stay (days)	7.4	6.0	0.001

15.4. Economic evidence

Published literature

No relevant economic evaluations were identified.

See also the economic article selection flow chart in Appendix E.

15.5. Evidence statements

Clinical

Checklist versus no checklist

Very low quality evidence from a single observational study comprising 1622 participants demonstrated no clinical difference between a checklist and no checklist for mortality or complications, with very serious and serious imprecision.

Electronic medical record versus no electronic medical record

Very low quality evidence from three cohort studies comprising 200, 5999 and 7519 participants, respectively, demonstrated no clinical difference between an electronic medical record and no electronic medical record for mortality, with no serious imprecision.

Very low quality evidence from one cohort study comprising 200 participants demonstrated a clinical benefit of an electronic medical record compared with no electronic medical record for requiring severe surgery, with serious imprecision.

Very low quality evidence from one cohort study comprising 200 participants demonstrated no clinical difference between an electronic medical record and no electronic medical record for a delay in diagnosis, with serious imprecision.

Low to very low quality evidence from one cohort study comprising 5996 participants demonstrated no clinical difference between an electronic medical record and no electronic medical record for airway complications, cardiac arrest, wound infection and drug complications, with no to very serious imprecision.

Very low quality evidence from one cohort study comprising 5996 participants demonstrated a clinical benefit of an electronic medical record compared with no electronic medical record for completeness of data (floor notes, procedure notes, resuscitation notes and ICU notes), with no serious to serious imprecision.

Low quality evidence from one cohort study comprising 807 participants demonstrated a clinical benefit of an electronic medical record compared with no electronic medical record for missing cases (diagnosis, mechanism of injury and a treatment plan), with no serious imprecision.

Economic

No relevant economic evaluations were identified.

15.6. Recommendations and link to evidence

Recommendations	Recording information in pre-hospital settings 67. Record the following in patients with major trauma in pre-hospital settings: catastrophic haemorrhage airway with in line spinal immobilisation breathing circulation disability (neurological) exposure and environment (<C>ABCDE) 68. If possible, record information on whether the assessments show that the patient's condition is improving or deteriorating. 69. Record pre-alert information using a structured system and include all of the following: the patient's age and sex time of incident mechanism of injury injuries suspected signs, including vital signs and Glasgow Coma Scale treatment so far estimated time of arrival at emergency department special requirements the ambulance call sign, name of the person taking the call and time of call. Receiving information in hospital settings At the emergency department 70. A senior nurse or trauma team leader in the emergency department should receive the pre-alert information and determine the level of trauma team response according to agreed and written local guidelines. 71. The trauma team leader should be easily identifiable to receive the handover and the trauma team ready to receive the information. 72. The pre-hospital documentation, including the recorded pre-alert information, should be quickly available to the trauma team and placed in the patient's hospital notes. Recording information in hospital settings 73. Record the items listed in recommendation 67, as a minimum, for the primary survey. 74. One member of the trauma team should be designated to record all trauma team findings and interventions as they occur (take ‘contemporaneous notes’). 75. The trauma team leader should be responsible for checking the information recorded to ensure that it is complete. Sharing information in hospital settings 76. Follow a structured process when handing over care within the emergency department (including shift changes) and to other departments. Ensure that the handover is documented. 77. Ensure that all patient documentation, including images and reports, goes with patients when they are transferred to other departments or centres. 78. Produce a written summary, which gives the diagnosis, management plan and expected outcome, and: is aimed at and sent to the patient's GP within 24 hours of admission includes a summary written in plain English that is understandable by patients, family members and carers is readily available in the patient's records.
	These recommendations were developed and supported by the evidence reviews addressing the scope area ‘documentation of clinical assessments and management (including pre-hospital and hospital)’ in each of the four clinical guidelines: Complex fractures: assessment and management of complex fractures (including pelvic fractures and open fractures of limbs) Fractures: diagnosis, management and follow up of fractures (excluding head and hip, pelvis, open and spinal) Major trauma: assessment and management of airway, breathing and ventilation, circulation, haemorrhage and temperature control. Spinal injury assessment: assessment and imaging, and early management for spinal injury (spinal column or spinal cord injury) and ‘patient documentation and transfer of information’ in the major trauma services guidance scope area. The chapters on documentation in these guidelines should be read in conjunction with this chapter. Developing the recommendations Documentation recommendations were developed across the trauma guidelines suite by all the individual GDGs. Each GDG was asked to define a clinical question to address the scope area that was specific and important to the population in their scope. Evidence reviews were completed for all the guidelines and the separate GDGs reviewed the evidence and drafted recommendations. It should be noted that the spinal injury and complex fractures populations are subsets of the overall major trauma population. The overall guideline population of patients with major trauma meant that similarities and duplication between the draft recommendations were inevitable. The recommendations were taken to project executive team (PET) for coherence and consistency checking. The PET also had the advantage of identifying gaps in the separate guidelines that had been addressed in another guideline. The PET agreed on a core set of draft recommendations that encompassed the separate recommendations. These recommendations are a key set of principles that underline best practice in documenting and communicating the management of a patient with major trauma. Where recommendations were specific to the guideline these were kept separate for publication in that guideline. For example, the spinal injury guideline has a documentation recommendation on the ASIA chart. The core set of recommendations were taken back to each of the separate GDGs for review and agreement. The GDGs had access to the reviews underpinning the recommendations. The recommendations listed in this guideline are clinical aimed at clinical staff The recommendations for organisations are in the Major Trauma services guidance. The LETR in this chapter summarises the decision making of the major trauma GDG.
Relative values of different outcomes	The GDG identified mortality, health-related quality of life and complications as critical outcomes in evaluating the clinical effectiveness of standard documentation for major trauma patients. The GDG also identified hospital length of stay, patient-reported outcomes (return to normal activities and psychological wellbeing), missing patient data, and the timing of patient transfer as important outcomes. No evidence was reported for quality of life.
Trade-off between clinical benefits and harms	Five retrospective cohort studies were included in the review. One study Implemented a checklist and four studies implemented electronic records. Checklists were associated with reduced length of stay but there were no clinically important differences in mortality or complications. Overall, the use of electronic medical records was associated with less missing data, a reduced need for serious surgery and a shorter length of in-hospital stay when compared with non-electronic recording of data. The evidence did not suggest any clinical harm of using standard documentation. The GDG felt that the evidence included in the review did not evaluate the clinical effectiveness of standard documentation, as the studies compared different methods of recording patient data. However, it was likely that the use of electronic records indirectly led to more standardised reporting. The GDG discussed how standard documentation (pre-hospital and hospital) across the trauma networks for trauma patients may improve clinical outcomes for patients by ensuring that all key aspects of patients' needs and treatment plan are recorded, and that these are communicated between clinicians. Using standard reporting forms also facilitates the monitoring of any change in physiological status. However, it was noted that there would be a trade-off between standardisation of procedure to promote consistency and being too prescriptive in that main message may become lost. Too little information recorded may be insufficient to realise the key benefits (such as improved patient outcomes) whereas too much information could hinder timely transfer of information. There would also be trade-offs in between catering for local needs within geographical boundaries versus uniformity across the country. The GDG emphasised the importance of ensuring that the documentation is completed. Whilst the trauma team leader should be responsible for checking that the information is complete, another member of the trauma team may be designated with the responsibility of recording findings and interventions and this may vary according to who is in attendance.
Trade-off between net health benefits and resource use	No economic evidence was identified for this question. Staff time is likely to be the major difference in resources of having set procedures or longer forms to fill in. There are potential costs associated with staff training and the development, purchasing and maintenance of electronic systems and software. Some costs may be offset by decreased workloads due to computerisation of manual records and reduced clinical costs of adverse events due to improved safety. It was also noted that uniformity of the documentation process and protocol, through an economy of scale, could be less expensive for the NHS than implementation of disparate systems. There are several benefits that are likely to stem from having a standardised system across settings, for example, less likely to miss key information about the patient, less time spent re-assessing the patient to perhaps fill in missing fields, less time spent transferring the information from one system to another/or one format to another, and therefore less likely for there to be errors which can lead to poorer outcomes or mistakes. Five clinical studies were identified, although, the GDG felt that these did not adequately capture the question, as they compared the recording of data in one form compared with another form, rather than the standardisation of documentation across different settings. However, they did seem to show that electronic systems had a positive impact on outcomes, such as reduced time between admissions and completion of care, and reduced length of stay, which can have an impact on resource use and delay the patient in receiving treatment. The recommendations made list the data that should be included in a standard documentation.
Quality of evidence	All the evidence was from non-randomised, retrospective cohort studies at high or very high risk of bias. Furthermore, the GDG felt that the evidence evaluated the clinical effectiveness of different methods of recording data, but does not fully capture the impact of standardised documentation.
Other considerations	The GDG agreed on a consensus recommendation that would facilitate the integration of systems across clinical settings and allow for seamless transition of documentation when the patient is transferred from one setting to another. The GDG also agreed that the main aim of standardised documentation is to ensure that the information is uniform. This ensures that different services and departments understand each other, this can be with something as simple as using the same words. The GDG developed consensus recommendations that supported the use of minimum data sets in both the pre-hospital and hospital settings. The GDG highlighted the importance of a clear line of responsibility for completing documentation at all stages of the patient journey. These recommendations also facilitate the accurate and complete collection of research and audit data.

Bookshelf ID: NBK368110

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