A little over a year ago, I started a new job as a trauma registrar. I’m still working a few shifts on a 911 ambulance, but being a registrar is a great job for a paramedic who doesn’t want to be jumping in and out of rigs full time the rest of their career! This position draws on my knowledge of anatomy and pathophysiology, my experience in the healthcare system, and my passion for trauma care.
During my orientation, I was pleasantly surprised to find out just how much information from the EMS patient care record (EMS PCR) is abstracted by trauma registrars and included in the variety of ways the data is used by the trauma system. On the flip side, I saw an opportunity for EMS providers to improve their documentation to help improve trauma care.
This article will highlight some of the fields on an EMS PCR that are important to the trauma registry and detail exactly what information registrars are looking for.
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What is a trauma registry?
Trauma registries are a critical part of the trauma care system and start at the local hospital level. Trauma centers have registrars who are trained to review healthcare records including EMS PCRs to abstract specific data about injured patients and enter that information into another database, or registry. There are also registries for cancer, cardiac care and a variety of specific or rare diseases scientists are studying. You have probably heard of the Cardiac Arrest Registry to Enhance Survival (CARES). When entering patient information, we “code” the various injuries identified as well as the care given to the patient. That information is then used at the local hospital level for trauma center management, performance improvement (PI) and injury prevention (IP). The data is also uploaded to state and national trauma registries to support higher level PI and IP as well as scientific research.
Top 5 ePCR fields
There are a few questions about trauma cases that seem to come up on a regular basis, and these are best answered by paramedics and EMTs as other healthcare providers do not usually get to see the scene for themselves.
- Time of incident. When did the patient actually get hurt? This timestamp is needed for every case and is often missing or unclear. Whenever possible, include the time of injury in your narrative or fill out the “Date/time of symptom onset” field. Even if it is an approximate time, that helps.
- Mechanism of injury (MOI). You have heard this many times and it is true. No one else gets to see the scene so any and all details about how the patient got hurt are helpful. Describe as many details as you can in the narrative. Your efforts to record the MOI are never wasted.
- Cause of a fall. It is no secret that falls are a major cause of EMS calls, hospitalizations, significant injury and even death. What led to the patient falling also matters as we work to implement fall-prevention programs. Falls generally “land” in one of three categories. Mechanical falls occur when the patient slips, trips or stumbles. This means the patient’s feet were primarily related to the fall. If the patient had any balance issues, dizziness, intoxication, near-syncope or weakness that led to the fall, those are not always considered mechanical and may be coded differently. Last but not least is the unwitnessed or unknown reason for a fall. The patient was found on the ground and does not know or cannot state what led to them being there. Include as many details as you can gather relating to the circumstances surrounding the fall.
- Location details. Any information about the place the patient was injured is helpful. This includes the specific town or city, the type of street (residential, business, highway), as well as the type of building (private home, apartment, mobile home, assisted living, skilled nursing facility, restaurant, store, factory, etc.). For places of residence, we like to know the specific room in the building, too (e.g., bedroom, bathroom, kitchen, garage, yard, etc.)
- Safety equipment. Was the patient using any devices that may have helped reduce the impact of the mechanism of injury? Seat belts, airbags, helmets, protective clothing, eye protection and child car seats all qualify as safety gear. For seat belts, airbags and child car seats, more specific details, such as lap belt and/or shoulder belt, which airbags deployed, and what type of car seat are appreciated.
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Now that we have the top 5 fields out of the way, let’s take a look at a few other data elements that give EMS providers an opportunity to contribute to better trauma documentation, patient care, performance improvement and injury prevention.
Documenting motor vehicle crashes
MVCs are another very common way that patients get injured and are an area where injury prevention efforts have helped save lives over the years. To help focus those IP projects, it is important to know as much about crash patterns as we can. These details are entered into the trauma registry and include the types of vehicles involved (e.g., car, SUV, pickup truck, large truck) and the areas that the vehicle(s) were impacted (e.g., front, passenger side, driver side, rear, rollover). It is also good to know if the patient was the driver or passenger. This may not always be apparent and — in some cases — the patients may not readily disclose the information (e.g., if driving under the influence) but document if it is known.
E-bikes and off-highway vehicles
Two other categories of MOI that also deserve a little extra attention are electric bikes and scooters, and off-highway vehicles (OHVs). Each of these represent growing recreational opportunities, but unfortunately, this also means increased injuries and fatalities. Documenting that the patient was on an e-bike or e-scooter is very helpful even if you do not know what category or power rating the device had. OHVs include a wide variety of vehicles including utility terrain vehicles (UTVs), also known as side-by-sides; as well as three- and four-wheeled all-terrain vehicles (ATVs). Any additional details describing what type of vehicle the patient was in will be useful.
Loss of consciousness
This is another factor where details can get sketchy, but any information you can provide about witnessed or reported loss of consciousness (LOC) will help substantiate other information the trauma team gets. Some head injury coding differentiates whether there was a LOC and if so, how long it lasted. EMS confirmation of an LOC is more valuable than when the patient or a bystander reports it.
Injuries found on assessment
One of the most challenging parts of entering a case in the trauma registry can be finding all the injuries the patient sustained. Even minor wounds, such as abrasions and contusions, are recorded so that we can have the best possible picture of how injured the patient was. It is understood that with major trauma patients, EMS providers need to focus on treating life-threatening conditions and that you do not always have time to document a thorough head-to-toe assessment, but when you do have the chance, this information is helpful.
It is also useful to note the specific body part when recording injuries. In the registry, we differentiate between upper arm and lower arm, and the same with legs. If the injury is on a knee, elbow, ankle, wrist, shoulder, hip, hand or foot, those descriptions all help us code the injury better. If someone has an injury on their head, we consider the scalp as any area that is within the normal hairline.
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Past medical history
Certain conditions or comorbidities have an impact on how patients respond to and heal from traumatic injuries. These are also entered into the trauma registry, and it is beneficial when they are noted in the EMS PCR. Some of these conditions include:
- Current tobacco smoking (including vaping)
- Anticoagulation medications
- Bleeding disorders
- Hypertension
- Diabetes
- Heart failure
- Recent myocardial infarction
- Stroke with residual effects
- Pregnancy
- Steroid use
- Liver disease
- Kidney disease requiring dialysis
- Certain behavioral health/personality disorders
ePCR
Many other areas of the run report are important, of course, including the care you provided, where and how the patient was transported, and the operational times. Improving the accuracy and completeness of all these data points will not only help improve data submitted to the trauma registry, but also the information fed into state databases and the National EMS Information System (NEMSIS). The care you provide saves lives, and your documentation can, too.
Stay safe out there.
