Dataset Information

Association Between Real-time Electronic Injury Surveillance Applications and Clinical Documentation and Data Acquisition in a South African Trauma Center.

ABSTRACT: Importance:Collection and analysis of up-to-date and accurate injury surveillance data are a key step in the maturation of trauma systems. Trauma registries have proven to be difficult to establish in low- and middle-income countries owing to the burden of trauma volume, cost, and complexity. Objective:To determine whether an electronic trauma health record (eTHR) used by physicians can serve as simultaneous clinical documentation and data acquisition tools. Design, Setting, and Participants:This 2-part quality improvement study included (1) preimplementation and postimplementation eTHR study with assessments of satisfaction by 41 trauma physicians, time to completion, and quality of data collected comparing paper and electronic charting; and (2) prospective ecologic study describing the burden of trauma seen at a Level I trauma center, using real-time data collected by the eTHR on consecutive patients during a 12-month study period. The study was conducted from October 1, 2010, to September 30, 2011, at Groote Schuur Hospital, Cape Town, South Africa. Data analysis was performed from October 15, 2011, to January 15, 2013. Main Outcomes and Measures:The primary outcome of part 1 was data field competition rates of pertinent trauma registry items obtained through electronic or paper documentation. The main measures of part 2 were to identify risk factors to trauma in Cape Town and quality indicators recommended for trauma system evaluation at Groote Schuur Hospital. Results:The 41 physicians included in the study found the electronic patient documentation to be more efficient and preferable. A total of 11?612 trauma presentations were accurately documented and promptly analyzed. Fields relevant to injury surveillance in the eTHR (n?=?11?612) had statistically significant higher completion rates compared with paper records (n?=?9236) (for all comparisons, P?

SUBMITTER: Zargaran E

PROVIDER: S-EPMC5875377 | biostudies-literature | 2018 May

REPOSITORIES: biostudies-literature

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Association Between Real-time Electronic Injury Surveillance Applications and Clinical Documentation and Data Acquisition in a South African Trauma Center.

Zargaran Eiman E Spence Richard R Adolph Lauren L Nicol Andrew A Schuurman Nadine N Navsaria Pradeep P Ramsey Damon D Hameed S Morad SM

JAMA surgery 20180516 5

<h4>Importance</h4>Collection and analysis of up-to-date and accurate injury surveillance data are a key step in the maturation of trauma systems. Trauma registries have proven to be difficult to establish in low- and middle-income countries owing to the burden of trauma volume, cost, and complexity.<h4>Objective</h4>To determine whether an electronic trauma health record (eTHR) used by physicians can serve as simultaneous clinical documentation and data acquisition tools.<h4>Design, setting, an ...[more]

PMID: 29541765

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Project description:ImportanceFollowing the adoption of electronic health records into a regulatory environment designed for paper records, there has been little investigation into the accuracy of physician documentation.ObjectiveTo quantify the percentage of emergency physician documentation of the review of systems (ROS) and physical examination (PE) that observers can confirm.Design, setting, and participantsThis case series took place at emergency departments in 2 academic medical centers between 2016 and 2018. Participants' patient encounters were observed to compare real-time performance with clinical documentation.ExposuresResident physicians were shadowed by trained observers for 20 encounters (10 encounters per physician per site) to obtain real-time observational data; associated electronic health record data were subsequently reviewed.Main outcomes and measuresNumber of confirmed ROS systems (range, 0-14) divided by the number of documented ROS systems (range, 0-14), and number of confirmed PE systems (range, 0-14) divided by the number of documented PE systems (range, 0-14).ResultsThe final study cohort included 9 licensed emergency medicine residents who evaluated a total of 180 patients (mean [SD] age, 48.7 [20.0] years; 91 [50.5%] women). For ROS, physicians documented a median (interquartile range [IQR]) of 14 (8-14) systems, while audio recordings confirmed a median (IQR) of 5 (3-6) systems. Overall, 755 of 1961 documented ROS systems (38.5%) were confirmed by audio recording data. For PE, resident physicians documented a median (IQR) of 8 (7-9) verifiable systems, while observers confirmed a median (IQR) of 5.5 (3-6) systems. Overall, 760 of 1429 verifiable documented PE systems (53.2%) were confirmed by concurrent observation. Interrater reliability for rating of ROS and PE was more than 90% for all measures.Conclusions and relevanceIn this study of 9 licensed year emergency medicine residents, there were inconsistencies between the documentation of ROS and PE findings in the electronic health record and observational reports. These findings raise the possibility that some documentation may not accurately represent physician actions. Further studies should be undertaken to determine whether this occurrence is widespread. However, because such studies are unlikely to be performed owing to institution-level barriers that exist nationwide, payers should consider removing financial incentives to generate lengthy documentation.

Project description:There is an upward trend in facial injuries following changes in population pattern, increasing industrialization and urbanization, hence maxillofacial trauma is becoming a burden and a leading medical problem in emergency rooms worldwide. This study was performed to evaluate the pattern of maxillofacial fractures, associated injuries, and treatment used at Jai Prakash Narayan Apex Trauma Center (JPNATC), All India Institute of Medical Sciences (AIIMS), New Delhi, India, between January 2007 and June 2010. The study provides basis for establishment of trauma as major etiology of maxillofacial injuries and planning for preventive strategies. A retrospective study of patients seen and treated at JPNATC, AIIMS, New Delhi, between January 2007 and June 2010 was performed. Data extracted from patient records included etiology, age, sex, types and sites of fractures, treatment modality, and concomitant injuries. There were 795 fractures of the maxillofacial skeleton and 86 concomitant injuries from 542 patients. Road traffic accident (RTA) (56.8%) was the most common etiologic factor, followed by falls (22.3%) and fights (18.5%). The age range was from 3 to 75 years (mean, 34.7 years) with a peak incidence in the third decade with a male-to-female ratio of 3.7:1. The most common location of maxillofacial fractures was the mandible 615 (77%) and middle third 180 (23%). With regard to mandibular fractures, the body (29.6%) was the most common site, followed by the angle (24.4%), ramus (19.5%), dentoalveolar (14.6%), symphysis (11.0%), condyle (0.8%) while in the middle third, the nasal bone (36.7%) was the most common, followed by zygomatic bone (27.8), Lefort II (14.4), Lefort I (7.8%), dentoalveolar (10.0%), and Lefort III (3.3%). Majority of the patients were treated by open reduction and internal fixation (70.6). Concomitant injuries were 84 (10.8%) with orthopedic injuries accounting for the majority (63.9%). Head injury was associated in 16.3% of cases. RTA was the major etiologic factor of maxillofacial injuries in our setting and the young adult males were the main victims. Henceforth, establishment of regionalized, efficient, and focused trauma centers in various parts of the country particularly for acute trauma should be emphasized. Also, the laws regarding the precautions such as seat belts, speed limits, and traffic rules must be observed strictly to reduce the incidence of RTA.

Dataset Information

Association Between Real-time Electronic Injury Surveillance Applications and Clinical Documentation and Data Acquisition in a South African Trauma Center.

Publications

Association Between Real-time Electronic Injury Surveillance Applications and Clinical Documentation and Data Acquisition in a South African Trauma Center.

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