Impact of a statewide trauma system on rural emergency department patient assessment documentation

Objective: To determine the association of rural ED patient assessment documentation with state trauma system implementation, hospital trauma categorization level (i.e., Level-3 vs Level-4), injury diagnosis, and patient demographics. Methods: A pre- vs post-system implementation (historical control) analysis of trauma documentation was performed using a sample of rural ED trauma patients from 4 Level-3 and 5 Level-4 trauma hospitals. The medical records of patients with specific index diagnoses in 4 anatomic regions (head, chest, liver/spleen, and femur/open-tibia) were reviewed for 3-year periods before statewide trauma system implementation and after hospital categorization. Vital sign, % inspired O₂, and O₂ saturation determinations were identified relative to the first and the last vital signs documented on the ED record. If not documented in the medical chart within 5 minutes of the first or last ED vital sign assessment, these measurements were considered missing. Separately, neurologic documentation (initial and final) also was sought for patients meeting criteria for an index head injury. Results: Of 1,057 patients entered into the database, 532 were evaluated during the pre-system period and 525 were evaluated during the post-system period. Overall, 47% had a head injury, 34% had a chest injury, 23% had a femur/open-tibia injury, and 12% had a spleen/liver injury. There were 142 (13%) patients with an injury in >1 index area. Except for initial systolic blood pressure, documentation of all other initial and final patient vital signs increased significantly (p < 0.05). Documentation of the Glasgow Coma Scale score (initial and final; p = 0.0001) and a final pupil examination on head-injured patients (p = 0.025) also increased. The effects of hospital level, injury diagnosis, and patient demographics on documentation rate were minimal. Conclusion: The study found overall improved ED documentation of trauma patient status in association with implementation of a statewide trauma system. This improvement in documentation suggests an enhanced process of care with trauma system participation.