Helicopter emergency medical service registrars do ...

Original article 1

Helicopter emergency medical service registrars do not comprehensively document primary surveys Sandra Ware, Cliff Reid, Brian J. Burns and Karel Habig Objectives In-hospital primary surveys undertaken on traumatically injured patients can be inaccurate and incomplete. This study examined the documentation of prehospital primary surveys conducted by Greater Sydney Area Helicopter Emergency Medical Service registrars on trauma patients. Methods A retrospective case sheet review of prehospital trauma primary surveys documented by Greater Sydney Area Helicopter Emergency Medical Service registrars was carried out using previously published methodologies. A 13-item prehospital primary survey score was created and analysed by registrar specialty. A linear mixed model was used to determine whether differences in prehospital primary survey score existed between specialties. A one-point difference in the mean scores was considered clinically significant.

identified for individual registrars (v21d.f. = 6.03, P = 0.01). A very good level of agreement was obtained between the PPSS raters (j = 0.93, 95% confidence interval, 0.87–0.99). Conclusion Helicopter emergency medical service registrars do not comprehensively document prehospital primary surveys on traumatically injured patients. However, emergency medicine trainees document more completely than anaesthetic trainees. Individual registrar variation contributes significantly towards the completeness of prehospital primary survey documentation. European Journal of Emergency Medicine c 2012 Wolters Kluwer Health | Lippincott 00:000–000 Williams & Wilkins. European Journal of Emergency Medicine 2012, 00:000–000 Keywords: emergency medical services, prehospital, primary survey

Results A total of 75 charts were reviewed. An unadjusted mean of 9.5±1.6 (SD) items, out of a possible 13, was documented. Documentation was found to be less complete for anaesthetic trainees (adjusted mean score = 9.10) than for emergency medicine trainees (adjusted mean score = 10.34). The difference in the mean scores was 1.24 (95% confidence interval, 0.25–2.23, t53d.f. = 2.52, P = 0.01). A significant clustering effect was

Introduction Perhaps the most important principle of prehospital trauma care is the concept of the primary survey, enabling the rapid and systematic identification of life-threatening problems and simultaneous resuscitation. All patients, no matter what their presenting problem, require a methodical assessment and risk stratification process so that their need for treatment and the level of urgency related to this are clearly identified. The best way to do this is to systematically examine patients in the ABCDE order in which we know problems affect their health most directly, airway, breathing, circulation, disability, and exposure, otherwise known as the primary survey. Once performed, the primary survey provides a set of observations that enable an accurate assessment of the clinical condition of the patient. Where assessment details are not recorded, they may be interpreted as though they did not occur. The ABCDE systematization of the primary survey has its origin in the advanced trauma life support approach to assessing and managing multiply injured patients, first

Greater Sydney Area Helicopter Emergency Medical Service, Georges Hall, New South Wales, Australia Correspondence to Sandra Ware, BSc, MSc(Med), Greater Sydney Area Helicopter Emergency Medical Service, PO Box 58, Georges Hall, NSW 2198, Australia Tel: + 61 297 078 819; fax: + 61 297 078 898; e-mail: [email protected] Received 9 January 2012 Accepted 14 May 2012

published in 1980 by the American College of Surgeons [1]. Previous studies have shown inadequacies in the conduct and documentation of in-hospital primary surveys, across medical specialties and levels of training [2–4], but no studies have examined the completeness of prehospital primary surveys. The expanding use of helicopter emergency medical services (HEMS) to attend prehospital major trauma means that trainee doctors with emergency or anaesthetic backgrounds are often the first physicians to evaluate seriously injured patients. Deficiencies in the conduct or the documentation of their primary survey could lead to improper transport or treatment and missed injuries. Objectives

The objectives of this study were to benchmark the standard of prehospital primary surveys documented by trainee registrars within the Greater Sydney Area Helicopter Emergency Medical Service (GSA-HEMS) and to determine whether differences exist along specialty lines.

Methods Study design

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (www.euro-emergencymed.com). c 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins 0969-9546

This was a retrospective case sheet review of patients with prehospital injuries. The methodologies of Sarko [5] and Gilbert et al. [6] were followed. The Sydney DOI: 10.1097/MEJ.0b013e328355e48c

Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

2 European Journal of Emergency Medicine 2012, Vol 00 No 00

Southwest Area Health Service (RPAH Zone) Human Research Ethics Committee approved the study. Study setting and population

GSA-HEMS is a prehospital and retrieval medicine service serving critically ill and injured patients in New South Wales, Australia. GSA-HEMS physicians work with paramedics and flight nurses on helicopters, fixed wing aircraft and road ambulances, and currently undertake around 2500 missions per year from bases in Sydney, Wollongong and Orange. Trauma patients of all ages were eligible for this study if they were attended by a GSA-HEMS registrar at the scene of an incident. Patients were excluded if they had only minor injuries, identified by same-day hospital discharge, and patients who were attended solely for access reasons or not transported with GSA-HEMS personnel. Study protocol

A search of the available literature failed to show any standardized or validated method for evaluating a prehospital primary survey. Therefore, a prehospital primary survey score (PPSS) was created by listing those Components of a primary survey considered by senior GSA-HEMS consultants to be important for the prehospital evaluation of a trauma patient. The final score comprised respiratory and heart rates, SpO2, FiO2, blood pressure, Glasgow Coma Scale (GCS), limb movements and chest, airway, abdomen, pupillary, pelvic and long bone examination. The presence or absence of each of these items was scored as 1 or 0, respectively, and summed to a total score with a potential range from 0 to 13 (see appendix, Supplemental digital content 1, http://links.lww.com/EJEM/A27). Medical records of GSA-HEMS trauma patients were reviewed by hand to identify eligible cases over a 6-month period. Case sheet documentation comprised a combination of free form handwritten text and specified fields. Variables were defined a priori and a training manual was prepared. After a period of training, a single researcher, not blinded to the study objective but blinded to registrar specialty, abstracted data directly into a standardized electronic data collection form. Twenty percent of case sheets (n = 15) were abstracted by a second researcher for comparison. No abstraction or coding difficulties were encountered during the study. Statistical analysis

The primary outcome was the mean PPSS. Fifteen case sheets were reviewed before the study began, with a mean of 9.5±1.5 (SD) items documented. A finding of a 1-point (8%) difference in the mean PPSS between specialties was considered a priori to be sufficient to warrant specific redress through our induction curricula. On the basis of a desired power of 80% and an a error rate of 5%, we determined that more than 70 case sheets were necessary for this study.

Because an individual registrar examined more than one patient, the scores were not independent of each other. To account for this clustering effect, a linear mixed model was used in which the individual registrar was treated as a random effect and registrar specialty as a fixed effect. The significance of the individual registrar effect was examined by comparing the – 2log likelihoods obtained with and without its inclusion. Values of P less than 0.05 were considered statistically significant. Data were initially entered into an Excel (Microsoft Inc., Redmond, Washington, USA) spreadsheet and then transferred to SAS version 9.2 (SAS Institute Inc., Cary, North Carolina, USA) for analysis.

Results Seventy-five case sheets completed by 22 registrar trainees [seven emergency trainees (ET), 15 anaesthetic trainees (AT)] were reviewed (Table 1).

Table 1

Patient and mission characteristics n (%)

Characteristics Mechanism Falls Fall high > 5 m Fall low < 1 m Fall medium 1–5 m MVA MB rider MV back passenger MV driver MV front passenger MV passenger (unknown location) Other Pedal cyclist Pedestrian Recreation/sport Train Horse Industrial Other Transport mode Helicopter Road Fixed wing Sex Female Male Trapped on arrival No Yes Night shift No Yes Intubated No Yes Multitrauma No Yes Total

AT

ET

Total

2 (5) 2 (5) 2 (5)

1 (3) 1 (3) 2 (6)

3 (4) 3 (4) 4 (5)

10 0 11 2 1

(23) (0) (25) (5) (2)

6 1 8 3 0

(19) (3) (26) (10) (0)

16 1 19 5 1

(21) (1) (25) (7) (1)

5 2 1 1 1 0 4

(11) (5) (2) (2) (2) (0) (9)

1 2 2 0 1 1 2

(3) (6) (6) (0) (3) (3) (6)

6 4 3 1 2 1 6

(8) (5) (4) (1) (3) (1) (8)

37 (84) 6 (14) 1 (2)

29 (94) 2 (6) 0 (0)

66 (88) 8 (11) 1 (1)

11 (25) 33 (75)

9 (29) 22 (71)

20 (27) 55 (73)

40 (91) 4 (9)

27 (87) 4 (13)

67 (89) 8 (11)

36 (82) 8 (18)

25 (81) 6 (19)

61 (81) 14 (19)

37 (84) 7 (16)

26 (84) 5 (16)

63 (84) 12 (16)

22 (50) 22 (50) 44 (100)

15 (48) 16 (52) 31 (100)

37 (49) 38 (51) 75 (100)

AT, anaesthetic trainees; ET, emergency trainees; MB, motorbike; MV, motor vehicle; MVA, motor vehicle accident.


Helicopter emergency medical service Ware et al.

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Fig. 1

Anaesthetic

100

Emergency

90 80

Percent

70 60 50 40 30 20 10 FiO2

Pelvis

Limb movement

Long bones

Abdomen

Pupils

rate ∗Respiratory

∗BP

Chest exam

∗GCS

2 ∗SpO

∗HR

Airway

0

Documented completeness by primary survey item. *Specified fields. BP, blood pressure; GCS, Glasgow Coma Scale; HR, heart rate.

Table 2

Fig. 2

Prehospital primary survey score inter-rater agreement Rater 1

Rater 1

Rater 1

Rater 2

No

Yes

Total

No Yes Total

45 2 47

3 145 148

48 147 195

14

Primary survey score

12

k = 0.93 (95% confidence interval, 0.87–0.99).

10

both groups, as was FiO2 (ET 39%, AT 41%, overall 40%). Specified fields were generally better documented than free-text fields (Fig. 1).

8

6

4 Emergency

Anaesthetic Specialty

Distribution of prehospital primary survey scores by trainee specialty. + Mean PPSS. PPSS, prehospital primary survey score.

Overall, registrars documented an average of 9.5±1.6 (SD) items. Limb movement and abdominal and pelvic examination were particularly poorly documented by AT (25, 43 and 36%, respectively). The exposure items, long bones (ET 48%, AT 55%, overall 52%) and pelvis (ET 48%, AT 36%, overall 41%), were poorly documented by

There was both a clinically and a statistically significant difference in the mean PPSS by trainee specialty: adjusted mean of 9.10 for AT versus 10.34 for ET [difference = 1.24 (95% confidence interval, 0.25–2.23, t53d.f. = 2.52, P = 0.01)]. The effect of any individual registrar on documented completeness was significant (w21d.f. = 6.03, P = 0.01), with average scores ranging from 7.0 to 11.7. The minimum and maximum scores attained were 5 and 13, respectively, and were normally distributed (Fig. 2). No abstraction or coding difficulties were encountered during the study. A k value of 0.93 (95% confidence interval, 0.87–0.99) was obtained for PPSS inter-rater reliability (Table 2).

Discussion Missed injuries contribute significantly towards patient morbidity and mortality [7,8]. Reported rates vary from


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1.4 to 65% depending on the study population, the definition of missed injury and the duration of follow-up [4–8]. Patient factors such as injury severity, multitrauma, intubation, blunt injury, motor vehicle mechanism and altered mental status (including intoxication) are associated with the occurrence of missed injuries [7–15]. Circumstantial factors such as night-time shifts may also be a factor. Root cause analyses have identified that omissions in the conduct of primary surveys contribute towards the occurrence of missed injuries [8,16,17]. Although far from evidential, omissions in primary survey documentation do raise concerns that omissions in primary survey conduct may also have occurred. A recent study found that the most commonly involved body region with a missed injury or a clinically significant missed injury was the head/neck, followed by the chest and the extremities. The highest incidence rate of clinically significant missed injuries occurred in the pelvis, chest and abdomen [18]. These findings mirror those of earlier studies [11,17]. We have found that primary survey items of relevance to head/neck injury, such as pupillary examination and limb movements, were poorly documented overall (ET 65%, AT 70%, overall 68% and ET 65%, AT 25%, overall 41%, respectively). GCS was more uniformly documented (ET 94%, AT 95%, overall 95%). Chest examinations were well documented (ET 100%, AT 89%, overall 93%) but pelvic, abdominal and long bone examinations were poorly documented (ET 48%, AT 36%, overall 41%; ET 71%, AT 42%, overall 55%; ET 48%, AT 55%, overall 52%, respectively). Tachycardia, tachypnoea and hypotension are nonspecific predictors of organ failure [14]. Primary survey items that identify these clinical entities such as heart rate (ET 100%, AT 98%, overall 99%), respiratory rate (ET 90%, AT 73%, overall 80%) and blood pressure (ET 100%, AT 89%, overall 93%) were well documented. These findings are reassuring as GCS, blood pressure and respiratory rate contribute towards the revised trauma score, frequently used as a prehospital triage and research tool [19]. In general, survey items that had specified fields were more completely documented than survey items that required free text entry. This observation has been made by others and has led to suggestions that preformatted forms might improve primary survey documentation [3,20]. This study also found significant variations in how thoroughly each registrar documented the primary survey. Deficiencies in documenting clinical examinations could reflect a knowledge difference, a skills’ difference or differences in the compulsiveness of documentation [5]. Scenario training has been shown to improve primary survey performance [21]. While all GSA-HEMS registrars have previously completed advanced trauma life support courses before appointment, our study findings have resulted in the incorporation of a workshop and simulation dedicated to prehospital primary survey performance into our physician induction training program.

Limitations

The PPSS was created by GSA-HEMS physicians for this study, and as such, it reflects the biases of the physicians involved, all of whom were Fellows of the Australasian College of Emergency Medicine. Other prehospital emergency medical services may not consider all items relevant. In the case of some life-threatening injuries, it may not be appropriate to perform a complete prehospital primary survey and patient care may not be compromised by relying on in-hospital surveys in those situations. In addition, no comparison was made of the extent of the documented prehospital primary survey with the occurrence of missed injuries, as the aim of this study was to identify the extent of the primary survey documented by GSA-HEMS registrars.

Conclusion This study found that GSA-HEMS registrars do not comprehensively document prehospital primary surveys in trauma. However, documentation by emergency medicine trainees is more complete than that of AT. Individual registrar variation contributed to the level of completeness. Given that the registrars involved in this study were drawn from the UK, Canada, USA and Australia, it is unlikely that these findings are isolated to GSA-HEMS.

Acknowledgements Funding was provided by the Aeromedical Division of the Ambulance Service of New South Wales. Conflicts of interest

There are no conflicts of interest.

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