2.50
Hdl Handle:
http://hdl.handle.net/10755/162362
Type:
Presentation
Title:
Creatively Communicated Cues to Improve Trauma Documentation
Abstract:
Creatively Communicated Cues to Improve Trauma Documentation
Conference Sponsor:Emergency Nurses Association
Conference Year:2010
Author:Berkihiser, Kristy L., RN, CEN
P.I. Institution Name:Penn State Milton S. Hershey Medical Center
Title:Emergency Department Staff Nurse
Contact Address:501 University Drive, Hershey, PA, 17034, USA
Contact Telephone:717-531-6902
[ENA Annual Conference - Evidence-based Practice Presentation]
Purpose: Trauma documentation in the Emergency Department serves as a record from which
Purpose: to assess and evaluate the quality of care given to trauma patients. Audits of this documentation can reveal areas for improvement in both the care of trauma patients and the recording of that care. The purpose of this project is to improve the documentation on the nursing trauma flow sheet, by using audit information in a positive and creative manner, to communicate to nursing staff the areas of improvement needed in trauma documentation.

Design: This quality improvement project stems from recognition of deficits in nursing documentation of trauma patient care. The project focuses on using information from audit results as stimulus to improve completeness of documentation and the quality of trauma care through creative, positive visual cues presented in a ôno-blameö format.

Setting: The setting for this quality improvement project is a Level One Audit and Pediatric Trauma Center in Pennsylvania.

Participants/Subjects: The participants in this project are the 86 registered nurses who provide and record the care of trauma patients. These nurses are randomly selected according to staffing patterns and incidence of trauma patient arrival.

Methods: Eight elements of trauma documentation were audited for 3.5 months, and deficits in the trauma record were identified. A large bulletin board was created by the trauma sub-committee, with bright visuals to attract attention. The bulletin board contained graphs depicting compliance, the trauma documentation policy and a sample trauma flow sheet with bullet pointers emphasizing the eight elements. Within the board were badge-sized "cheat sheets" for staff to take as a reminder of the eight vital elements needing improvement. In order to attract and hold staff attention, the bulletin board was conveniently placed next to the time clock where nurses wait to clock in and out each shift.

Results/Outcome: We have been auditing charts and providing in person, one on one feedback since mid September. We have improved our compliance with documentation of hypothermia treatment measures from 40% compliance to 68%. We have improved our documentation of hourly GCS' and pupil exam from 55% to 74%. We have improved our documentation of neurologic status from 23% to 74%. We have improved our documentation of intake and output from 50% to 87%. We have maintained our documentation statistics at greater than 90% in the areas of primary assessment and temperature documentation.

Implications: Results of this project suggest a creative means to communicate audit information in a format that will change staff practice in a positive manner. The bright visual cues motivated staff to recognize and improve documentation, and placement of the bulletin board was key to drawing staff attention and making constructive use of "waiting" time. Both the tool and its location serve as examples of means to inspire staff involvement in a quality improvement project.
Repository Posting Date:
27-Oct-2011
Date of Publication:
17-Oct-2011
Sponsors:
Emergency Nurses Association

Full metadata record

DC FieldValue Language
dc.typePresentationen_GB
dc.titleCreatively Communicated Cues to Improve Trauma Documentationen_GB
dc.identifier.urihttp://hdl.handle.net/10755/162362-
dc.description.abstract<table><tr><td colspan="2" class="item-title">Creatively Communicated Cues to Improve Trauma Documentation</td></tr><tr class="item-sponsor"><td class="label">Conference Sponsor:</td><td class="value">Emergency Nurses Association</td></tr><tr class="item-year"><td class="label">Conference Year:</td><td class="value">2010</td></tr><tr class="item-author"><td class="label">Author:</td><td class="value">Berkihiser, Kristy L., RN, CEN</td></tr><tr class="item-institute"><td class="label">P.I. Institution Name:</td><td class="value">Penn State Milton S. Hershey Medical Center</td></tr><tr class="item-author-title"><td class="label">Title:</td><td class="value">Emergency Department Staff Nurse</td></tr><tr class="item-address"><td class="label">Contact Address:</td><td class="value">501 University Drive, Hershey, PA, 17034, USA</td></tr><tr class="item-phone"><td class="label">Contact Telephone:</td><td class="value">717-531-6902</td></tr><tr class="item-email"><td class="label">Email:</td><td class="value">kberkihiser@hmc.psu.edu</td></tr><tr><td colspan="2" class="item-abstract">[ENA Annual Conference - Evidence-based Practice Presentation] <br/>Purpose: Trauma documentation in the Emergency Department serves as a record from which <br/>Purpose: to assess and evaluate the quality of care given to trauma patients. Audits of this documentation can reveal areas for improvement in both the care of trauma patients and the recording of that care. The purpose of this project is to improve the documentation on the nursing trauma flow sheet, by using audit information in a positive and creative manner, to communicate to nursing staff the areas of improvement needed in trauma documentation.<br/><br/>Design: This quality improvement project stems from recognition of deficits in nursing documentation of trauma patient care. The project focuses on using information from audit results as stimulus to improve completeness of documentation and the quality of trauma care through creative, positive visual cues presented in a &ocirc;no-blame&ouml; format.<br/><br/>Setting: The setting for this quality improvement project is a Level One Audit and Pediatric Trauma Center in Pennsylvania. <br/><br/>Participants/Subjects: The participants in this project are the 86 registered nurses who provide and record the care of trauma patients. These nurses are randomly selected according to staffing patterns and incidence of trauma patient arrival.<br/><br/>Methods: Eight elements of trauma documentation were audited for 3.5 months, and deficits in the trauma record were identified. A large bulletin board was created by the trauma sub-committee, with bright visuals to attract attention. The bulletin board contained graphs depicting compliance, the trauma documentation policy and a sample trauma flow sheet with bullet pointers emphasizing the eight elements. Within the board were badge-sized &quot;cheat sheets&quot; for staff to take as a reminder of the eight vital elements needing improvement. In order to attract and hold staff attention, the bulletin board was conveniently placed next to the time clock where nurses wait to clock in and out each shift.<br/><br/>Results/Outcome: We have been auditing charts and providing in person, one on one feedback since mid September. We have improved our compliance with documentation of hypothermia treatment measures from 40% compliance to 68%. We have improved our documentation of hourly GCS' and pupil exam from 55% to 74%. We have improved our documentation of neurologic status from 23% to 74%. We have improved our documentation of intake and output from 50% to 87%. We have maintained our documentation statistics at greater than 90% in the areas of primary assessment and temperature documentation. <br/><br/>Implications: Results of this project suggest a creative means to communicate audit information in a format that will change staff practice in a positive manner. The bright visual cues motivated staff to recognize and improve documentation, and placement of the bulletin board was key to drawing staff attention and making constructive use of &quot;waiting&quot; time. Both the tool and its location serve as examples of means to inspire staff involvement in a quality improvement project. <br/></td></tr></table>en_GB
dc.date.available2011-10-27T10:26:52Z-
dc.date.issued2011-10-17en_GB
dc.date.accessioned2011-10-27T10:26:52Z-
dc.description.sponsorshipEmergency Nurses Associationen_GB
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