Notes on Trauma: Poor Documentation Associated with Increased Mortality

We're taught throughout our career that "if it isn't written down, it didn’t happen." Whether working in the field, teaching or working as an administrator, I've always stressed the importance of thorough documentation to ensure continuity of care and to have a written history of this event in the patient's life, so a paper published in the February 2010 issue of the Journal of the American College of Surgeons was disturbing.

The paper, presented by Dann J. Laudermilch, BS, Melissa A. Schiff, MD, MPH, Avery Nathans, MD, MPH, PhD, FACS and Mathew R. Rosengart, MD, MPH, FACS, was titled "Lack of Emergency Medical Services Documentation Is Associated with Poor Patient Outcomes: A Validation of Audit Filters for Prehospital Trauma Care."

The article is about how trauma care needs a continued system of review to ensure it evolves and improves over time. The authors used a Delphi study with 81 nationally recognized experts in trauma care who were able to agree on 28 criteria that would be sensitive to monitoring variations in prehospital care. The criteria covered EMS care, transportation time and interfacility transfer. They then linked the prehospital and in- hospital records and sought to see if one or both of two factors influenced outcomes. The two things they looked at were cases where BLS requested ALS assist and failure of EMS personnel to record patient physiology at the scene.

They looked at 4,744 trauma patients in a retrospective cohort study. Of these, 1,337 patients had at least one scene physiologic parameter; 877 had no recorded heart rate; 925 were missing a recorded blood pressure and 1,195 were missing a respiratory rate. Seven hundred eighty-eight patients were missing all three values; 84 missed two and 465 were missing one. These are significant numbers. Just those with missing respiratory rates came to 25.2%.

Once they had this data, they looked for a correlation between their data and mortality. There was no association between BLS requesting ALS assist and increased mortality. The authors thought that dispatching BLS to patients needing ALS might affect outcomes, but, in this review, that was not the case. In regard to incomplete documentation, however, they found the association with increased mortality was more than twofold.

The authors recognizes that their study had limitations and noted, "Although our sample size was large, missing data of the level of EMS response limited our analysis and might have biased our results. Our ability to adjust for patient and injury characteristics was subject to the accuracy of chart documentation."

While I would like to say that omitting a vital sign from the patient record can't in itself cause more trauma patient deaths, I can't. This is the rub with poor documentation. You can't defend the quality of your assessment or treatment if the information is not recorded. In quality improvement programs, documentation is generally looked at to ensure protocol is followed, which is a big part of ensuring patients have their best chance at a good outcome. If we are looking to evaluate trauma patient care, our ability to study what works and what doesn't is hampered by incomplete documentation. Whether assessment findings or treatment, if we don't get it into the record, there are holes in the data and we can't evaluate the effectiveness of our trauma systems.

The authors of this study point out that inadequate EMS documentation might more globally measure inappropriate prehospital care. Think about that for a minute. If you are evaluating anything and find sloppy or incomplete documentation, you would assume that the work was suspect. It is not a stretch then to assume the possibility that incomplete documentation of our work in the field implies our care is incomplete as well.

At the very least, this study shows that we cannot know why these patients have poorer outcomes because the missing data becomes the target. If the data was there, it might show us other ways to improve these patients' chances. At the very worst, it reflects inferior care. That may infuriate you as a prehospital provider, but if you want to argue the point, you have to document it.

Will Chapleau, EMT-P, RN, TNS, is Advanced Trauma Life Support program manager for the American College of Surgeons, Chair of Prehospital Trauma Life Support for the National Association of Emergency Medical Technicians, and a member of EMS Magazine's editorial advisory board.