The impact of a qualified medical documentation assistant on trauma room management

For severely injured patients, effective diagnostics and treatment in the trauma room are crucial to the course of treatment and outcome of the patient. In recent decades, several improvements have been made to prehospital and early in-hospital treatment. Accordingly, the survival rate of severely injured patients has improved from 63 to 78% [1, 2].

One important factor for improving treatment effectiveness and quality is the use of intra- and inter-hospital benchmarking [1]. The inter-hospital quality assessment of the German Trauma Society (TraumaRegister DGU^®; TR-DGU) started with six German hospitals in 1993. Since then, the TR-DGU has increased greatly in scope. Currently, more than 600 hospitals from 11 countries are participating [3, 4]. Moreover, for German hospitals, participating in this registry is one of the requirements for the hospital’s certification as a trauma center (TraumaZentrum DGU^®).

For inter-hospital benchmarking, several quality indicators have been evaluated for inclusion in the TR-DGU [5, 6]. Thus, the quality of the documentation of trauma room diagnostics and treatment is crucial to ensure data quality. As such, standardized and structured documentation is necessary. In this respect, the German Interdisciplinary Association of Intensive and Emergency Care (DIVI) evaluated the German Emergency Department Medical Record (GEDMR). This documentation standard integrates the content of the TR-DGU, which avoids redundancies in the documentation process [7].

Ziprian et al. [8] evaluated data quality of 5409 TR-DGU treatment cases. There were several discrepancies, even for well-evaluated quality indicators such as the time to whole-body computed tomography (WBCT) [5, 8]. That is, initial documentation quality in the trauma room appears to be a major issue. In the current study, the primary outcome parameter was completeness of TR-DGU documentation. The aim of the study was to evaluate the impact of a medical documentation assistant (DA) on documentation completeness in the trauma room in comparison to documentation by physicians involved in direct patient treatment. We expected a better documentation completeness by DA.

This single-center study complied with the Helsinki Declaration (October 2013) and was approved by the Ethics Committee of the University of Magdeburg, Germany. The need to obtain written patient consent was waived by the Institutional Review Board, as the study strictly utilized anonymized data obtained from patient treatment and the trauma team. The STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) recommendations were applied with additional focus on study design [9]. Regarding the trauma room treatment, advanced trauma life support (ATLS) is practiced in our institution. The trauma room team was in same constellation in any of the included treatment cases. A medical documentation assistant (DA) was available between 07:00 and 17:00 on weekdays. The DA was a study nurse with a special training in medical documentation. Besides the medical documentation assistant, the trauma room team was the same at this time on weekdays, weekends, and public holidays. Thus, we divided the data in relation to the documentation assistant into three groups a priori: medical documentation assistant (DA, 07:00 to 17:00), physician in daytime (PD, 07:00 to 17:00) and physician at night (PN, 17:00 to 07:00).

From 01/2016 to 12/2016, the data of 251 trauma room patients (179 male, mean age 42.4 ± 17.9 years; 72 female, mean age 44.8 ± 20.7 years) were analyzed. There were 56 patients in the DA group, 86 in the PD group, and 109 in the PN group. The median injury severity score (ISS) of the entire sample was 4. There were no significant differences in median ISS between the DA group (6; IQR 16) and each of the PD group (4; IQR 13) and PN group (5; IQR 13; p = 0.721 by Kruskal–Wallis test; Fig. 1).

This study investigated the significance of a qualified medical documentation assistant in the trauma room setting of a German level-one trauma center. We compared the completeness of trauma room documentation conducted by a DA to documentation conducted by a physician involved in the direct treatment of the patient. The primary data quality was significantly better and the time to WBCT was shorter in the DA group. The ISS did not differ significantly among groups.

The TR-DGU is an important tool by which to improve the diagnosis and treatment of severely injured patients [14]. To achieve good data quality, it is important to prospectively register severely injured patients [15] and high-quality documentation quality is crucial [8]. As shown by Grundgeiger et al. [16], a possibility would be digitization of the documentation. They demonstrated that the use of a tablet-based application by a member of the emergency team could improve data quality without compromising clinical performance. However, the data quality reported to date is not optimal, even in level 1 trauma centers [8]. The logical consequence should be the professionalization of primary documentation and data input roles. In the presence of a qualified medical documentation assistant, the primary data completeness was significantly improved in our study. This implies lower cost and effort of entering the data of each trauma room case into the central TR-DGU documentation system. To achieve a better documentation quality, it is further necessary to perform the documentation immediately to the procedures in trauma room. For example, time stamps of the corresponding procedures were not plausible, if recorded retrospectively. As we record the information immediately, one physician is bound documenting the process of trauma room treatment. Therefore, the implementation of a documentation assistant releases one physician from documentation. Thus, this physician is able to support the trauma room treatment. However, this was associated with a shorter time to whole-body computed tomography (WBCT). WBCT plays a crucial role in trauma room diagnostics. It contributes to reducing mortality in patients with severe blunt trauma [17]. Time to WBCT is an important variable. Making available a CT scanner in the trauma room leads to reduced time to WBCT and thus helps reduce mortality among trauma room patients [18].

Regarding the estimated costs of a DA, it is necessary to implement an effectively workflow. In addition to the documentation in the trauma room, the DA in our institution carries out the input in the TraumaRegister DGU® and gathers the informed consent for input in the TraumaRegister DGU^® from the patients. Moreover, the DA cares for several clinical studies as study nurse. However, if documentation is carried out by physicians or emergency department nurses, it needs to take into account, that while documenting, they are not involved in the clinical examination and treatment of the patients. Therefore, it is necessary to offset the costs of a nurse/physician to the costs of the DA. Thus, it seemed to be very cost intensive, if this is a physician in comparison to a documentation assistant. The advantage in contrast to a nurse of the emergency department is the input of the information from the trauma room treatment in the TraumaRegister DGU^® by the same documentation assistant. In this regard, the DA knows exactly which information was obligatory and needed. Therefore, the effort for retrospective data acquisition is minimized. However, this implementation was established in a level 1 trauma center. Although the results showed improvements in documentation quality, a cost-effective implementation of a study nurse in other trauma centers or hospitals without clinical studies needs another implementation approach.

A limitation of our results is that causality could not be explicitly established; that is, although data completeness was better with a DA, we cannot state definitively that the DA led directly to the improved completeness. Furthermore, even though data completeness was poorer in PD and PN groups, a direct comparison group for the documentation assistant was not available. Moreover, DA was involved only on daytime. Therefore, bias in data interpretation is possible. Due to structural changes in 2017 that affected trauma room management data, data from 2017 and later could not be included. Thus, we only analyze 251 trauma room protocols.

In presence of a qualified medical documentation assistant, data completeness and time to WBCT improved compared to trauma room treatment with documentation completed by an involved physician. These findings need to be supported by an appropriate prospective randomized study. Nevertheless, implementation of a medical documentation assistant in trauma room treatment appears beneficial for primary data quality concerning information transfer to the attending physician as well as to health services research (e.g., the TR-DGU).