Concurrent Abstraction in Trauma
Wouldn’t we all like to live in a world where patient charts are started when the patient arrives and finished the day the patient leaves? Some of you may work in a hospital that embodies this type of process, but I believe more of us work in a hospital where this is not the case.
The Resources for the Optimal Care of the Injured Patient developed by the American College of Surgeons (ACS) requires that a minimum of 80% of trauma cases be entered within 60 days of discharge (CD 15-6). The trauma performance improvement and patient safety (PIPS) program must be supported by a registry and a reliable method of concurrent data collection that consistently obtains information necessary to identify opportunities for improvement (CD 15-3). These are both ACS Type II deficiencies.
Hospitals have many competing interests when it comes to their IT resources. For most Trauma Centers, this translates to trauma being at the bottom of a very long list. Trauma departments do not often have financial resources, but they could have buy-in from their stakeholders. Buy-in from these stakeholders could translate to convincing hospital administration that necessary support from IT could achieve much needed infrastructure updates.
There are many models for concurrent abstraction. Each hospital must define what concurrency means to them. Is it simply every chart is completed within 60 days of hospital discharge? Does it include a component that says every chart is started within 3 days of patient admission? Is the trauma registry looking at each patient multiple times during their stay? Daily?
The ideal model for any hospital will be sustainability and the ability to track and trend development. If process change is enacted, goals should be identified, and markers set to enable the tracking of progress. These should then be measured to see if the changes made have allowed for reaching the goals that were set.
One of the goals of concurrency is the ability to identify problems in real time and make any necessary changes in patient care to affect a positive outcome. Working within the hospital structure, this may entail assigning registry staff to attend daily rounds in order to capture the problems into the registry.
The hospital structure you work within may have a nurse champion who takes on this role and alleviates the use of a trauma registrar. This particular identification of patient care issues may require the allocation of laptops/phones/pads or other point-of-care (POC) IT related methods to capture information into the registry directly. Of course, recording these issues by hand and entering them into the registry later is an option if IT involvement is not available. If such a method is used, it is of no use if the patient has not been entered into the registry prior to rounds as a repository for identified performance improvement issues.
If you have the ability to change IT infrastructure, the ability to download data directly into the registry is a desirable option. Downloading this data limits keystroke errors in data entry. The challenge comes in identifying which data to directly download. This may include emergency services or ambulance data, demographic data, transferring hospital data, and other hospital-specific identified data. While direct downloads do not eliminate the need for verification, they can speed up data entry and therefore aid in concurrency. This may also enable the patient being entered in the registry prior to daily rounds.
Continuing education for trauma registrars is a necessary component to enable the identification of patients who meet audit filters or Trauma Quality Improvement Program (TQIP)-identified hospital events. This may be in the form of in-house education from the trauma team or other departments. There are also other entities that provide education on a fee-for-service basis.
A well-trained registrar is one who keeps current on changes both within and outside of the hospital. Well-trained registrars take less time to identify key issues impacting patient care and are a partner in efficient concurrent abstraction.
Concurrency can lead to engagement of trauma registrars. As an example, if they participate in daily rounding, the team gets to see them and know them. In turn, their role and their involvement may be valued by other team members. This in turn may lead to retention and job satisfaction.
Any plan to achieve concurrency will have to address the issue of adequate staffing. If you don’t have enough staff, no plan will be able to assist in achieving your goals.
At the time of this blog, the American College of Surgeons (ACS) Resources for the Optimal Care of the Injured Patient, or Orange Book, advocates one full-time equivalent (FTE) for each 500 – 750 admitted patients annually (CD 15-9) with the added note that “staffing need increases if additional data elements are collected”. The proposed new standard (which was supposed to be out at the time this blog is written) is 0.5 FTE for every 200 – 300 TQIP eligible patients.
Registrars whose job description does not entail duties other than abstraction are rare. Which side of the range your hospital falls on should be determined by the complexity and number of data points extracted for the registry.
COVID has had a huge impact on how hospitals and trauma departments handle day-to-day business. How a hospital conducts daily rounds and who is a part of this process may be something different than it was pre-COVID.
Adaptability is a key component of concurrent abstraction. Maybe it is time to overhaul the process by which concurrency is handled on a hospital-by-hospital basis. COVID may have initiated more efficient ways to achieve this goal. On the other hand, maybe COVID restrictions have hindered your efforts to maintain concurrency. It may be time to review the concurrency goals and see if they need to be updated in light of these changes.