Something to Ponder

I have been working at my clinical coordinator job for over six months now, and while I miss being on the ambulance during my desk job days (I still do 40 hours a week in 3 nondesk job days as a field medic), I am enjoying some aspects of the job — particularly the patient follow up and the data collection. (I remain at times distraught over the QI – torn between having to second guess medics and upholding certain standards of care and documentation).

I did not realize when I interviewed for the job that part of my duties included being the trauma data collector, and when I had it explained to me, I was not happy about. I have however, come to appreciate the insights this duty has given me.

As the trauma data collector, it is my job, per the data collection section of the Connecticut Trauma Regulations to input information from prehospital run forms, the ER records and the in house records for all admitted trauma patients at the hospital. Trauma, in Connecticut is defined as, “a wound or injury to the body caused by accident, violence, shock, or pressure, excluding poisoning, drug overdose, smoke inhalation, and drowning.”

To identify the patients, I sort through the ED data base to identify admitted patients with trauma diagnoses. I then open up each record and record information like time in the ED, procedures done, vitals, etc. If the prehospital run form has been scanned into the record, I can capture that information as well. Later I go down to medical records and pour through the charts to discover what procedures the patients had, how long they were in the hospital and what their outcomes were.

Since I work for a smaller, non trauma center hospital, the amount of information I enter is much less than it would be for a trauma center. At the end of the year, the information is sent off to the state, which collects and complies it.

The trauma patients who come to our hospital are predominately elderly and predominately the victims of low falls. (Major traumas in the area go to one of two trauma centers). I have been curious to read about other state’s trauma registries, and to discover that many exclude hip fractures from their registry. I guess there is a debate between surgeons on the issue. Some say a hip fracture is trauma, others that it is merely the end of a natural aging process. The bone becomes brittle and breaks almost of its own. Whether or not hip fractures are included can widely alter a state or hospital’s statistics.

As I may have mentioned before, I have been keeping a separate data base on hip fractures to record pain scales and time to analgesia both prehospitally and in the ED. Prehospitally, over a four month period, we received 39 hip fractures from EMS, only 4 (10%) of whom received prehospital analgesia. 87% needed analgesia in the ED. Part of the reason the prehospital number was so low is many of the area services utilize paramedic intercepts and medics in many cases are not even dispatched to the hip fracture calls. On the other hand, often a medic ambulance is sent and the medic ends up driving while the basic techs. Maybe unknown to the medic, but the basic is recording 9/10 and 10/10 pain scales for many of these patients, which is certainly a QI red flag.

I recently asked the state trauma data collector to try to ferret out the statewide stats on pain management, and the statistics were somewhat difficult for him to get from the collected data and are of somewhat uncertain reliability, but enlightening nonetheless.

There were 34,260 traumas patients admitted (admitted, died in ED or transferred to another acute hospital) to Connecticut hospitals between 2005 and 2007.

1,260 of these trauma patients received prehospital pain or sedation meds. (3.6%)

5,288 trauma patients had ICD-9 codes for hip fractures.

267 of these hip fracture patients received prehospital pain and sedation meds.(5%)

The problem is some hospitals evidently didn’t enter hip fractures, some prehospital run forms are missing, some patients, with no prehospital run form found, have prehospital meds listed from the ED records. Much depends on the quality of the data entry person and the quality of the records. The true number could be higher, but it is unlikely to be high enough to escape the “you have to be kidding me is this anyway to treat our elderly number!”

Speaking of QI, I just read an article where a research project was done where medics were paid $100 if they met certain QI objectives. In this study, with the promise of seeing cold hard cash, 100% of medics were in compliance with their “appropriate treatment of patients with traumatic hip pain” guidelines. The bottom line of the study was money talks more than a simple “Job Well done!”

That’s something to ponder.

Pay-for-Performance Incentives Might Improve Compliance

7 Comments

  • brendan says:

    The bottom line of the study was money talks more than a simple “Job Well done!”That’s something to ponder.I’ve pondered, and decided that if you need a cash bonus to do what you’re supposed to do anyway, I don’t want you anywhere near me or anyone I care about. If it’s burnout, get out. If you just don’t care, get out. If you’re lazy, get out. Please.

  • PC says:

    I agree. I found it…disturbing.

  • Medix311 says:

    That’s some interesting data you’ve collected. Thanks for taking the time and sharing it. In my system, hip fractures (if diagnosed in the field as such) are automatic ALS calls, meaning the medic techs the call. This leads to a much higher rate of our hip fracture patients receiving the prehospital pain meds they need. Something to consider, though. Not all hip fractures complain of pain and I’ve had some that even though they are in pain, have refused receiving analgesia.As an aside, my company is starting to institute a monetary bonus system. We’ll be looking at the completeness of a chart and the ability to bill the chart, total task times (time from dispatch to return to service), and positive comment cards received from patients. I agree that good patient care is something that should be inherent to the job and no one should receive an award or bonus for just “doing their job.”

  • Anonymous says:

    Out of the 84% of PTs who recieved analgesia in the ED surely they didn’t recieve IV analgesia. I mean if the paramedics didnt give it surely it wasn’t required later in hospital? So I am assuming these patients recieved oral analgesic in the ED like endone. So there for if your EMTs gave paracetamol they wouldnt be red flaged? arghhh paperwork is so frustrating here in Australia we get audited all the time due to these silly statistics.

  • PC says:

    All of these patients were admitted to the hospital for their injuries. They almost all recieved either IV morphine or IV dilaudid in the ED.

  • Anonymous says:

    We carry fentanyl and morphine. However, a lot of patients request, by name, Dilauded. I figured it felt pretty good, so I asked around. Here’s what one patient told me. “Dude, I have had it all. When I broke by back, they gave me morphine first. It was okay. But that didn’t cut the mustard. So they gave me Dilauded. Now, mind you, I am a child of the 70s. If it came in a pill, popper, powder or potion, I tried it once. “NEVER IN MY LIFE have I been as high was I was on Dilauded. It was 30 minutes of ecstasy, followed by about 3 hours of little pain. But for the first 30 minutes, you could sit in a vat of liquid poop and not care a bit in the world. It’s heavenly.”So, there you have it. Straight from the mouth of an ex-hippie.

  • Mikey says:

    Do people think the elderly cant feel pain? Hip fractures, dislocations, and closed fractures are constantly BLS-ed around here (Arizona). Its just plain old laziness. If you use morphine you have to get the waste witnessed, visit the pharmacy…so much hassle just to relieve someone’s suffering.

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