Trauma care in the emergency department
In this analysis communication problems were identified at all points in the continuum of patient care. Inadequate, delayed, or lack of communication between various healthcare professionals often resulted in critical patient information not being shared. The flow of information from other healthcare professionals to physicians was especially problematic.
The factors outlined below were identified as barriers to the delivery of quality trauma care.
Flow of information from pre-hospital and nursing personnel to physicians
- failure of pre-hospital personnel and triage nurses to share important clinical information (e.g. mechanism of injury, anticoagulation status)
- delay or failure of nursing personnel (i.e. in the emergency department, intensive care unit [ICU], ward, or penal institution) to notify the most appropriate physician of persistent symptoms or deterioration in the patient's condition
Flow of information from physicians to other physicians, healthcare professionals, and patients
- failure to review pre-hospital, referring hospital, and nursing records
- not communicating the trauma history or important clinical information to other physicians and nurses involved in the patient's care
- lack of ongoing coordination of care between all physicians involved
- delay or failure to assess the patient once advised of clinical deterioration
- not providing or documenting clear discharge instructions to the patient or family
- delay in advising a patient to return for treatment of an injury that was diagnosed following discharge (e.g. the final report of an X-ray differed from the preliminary interpretation)
Flow of information from hospital to physicians
- inadequate system to ensure imaging reports reached the appropriate physicians, particularly when further diagnostic imaging or follow up was recommended
Documentation is a key method of communication between physicians and healthcare professionals. In many of the cases, peer experts were critical of inadequate documentation of the examinations performed or specific examination results (e.g. neurological status), which created doubt about the thoroughness of the examination.
In the absence of documentation, the experts often questioned whether an examination or re-examination had actually been performed. Three general documentation deficiencies were identified:
- failure to document the diagnosis, trauma history, physical and laboratory findings, and imaging interpretation
- no discharge instructions
- illegible notes
Inadequate handover and illegible documentation
A 50-year-old woman with a history of diabetes, hypertension, and seizures was transported to the emergency department (ED) after falling and striking her head. On arrival, the pre-hospital personnel and family members reported that the patient had confusion and a decreased level of consciousness. The patient had also been vomiting for one day, attributed to eating in a local restaurant. The nurse triaged the patient as Canadian Emergency Department Triage and Acuity Scale (CTAS) Level 3 (urgent). The ED physician promptly performed a physical examination, including a neurological exam, which he documented as normal. Anchoring on the 24 hours of vomiting, he diagnosed gastroenteritis and wrote orders for overnight admission, an antiemetic, and intravenous rehydration. Prior to the end of his shift, the ED physician telephoned the on-call hospitalist to hand over the patient's care. He conveyed the patient's medical history, normal physical and investigative findings, and the need for rehydration to treat the gastroenteritis. However, he failed to mention the patient's recent trauma history.
Despite receiving antiemetics, the patient continued to vomit. She also began to complain of a headache and was incontinent of urine. The ED nurse notified the hospitalist by telephone of the change in the patient's condition, including the headache, and advised him of her recent fall. The hospitalist did not attend the patient, but ordered a CT scan of the head for the following morning.
The patient was then transferred to a medical unit. The ward nurse documented that the patient was responding very little and did not open her eyes, was vomiting and was incontinent of stool twice. However, she did not notify the physician. The hospitalist did not assess the patient until the next morning at which point significant neurological decline was noted. The patient was immediately referred to an internist. An urgent head CT scan revealed a large intracerebral hemorrhage. Following transfer to a tertiary hospital, a neurosurgeon determined the patient was not a neurosurgical candidate. She subsequently died.
The family lodged a medical regulatory authority (College) complaint alleging both the ED physician and the hospitalist failed to adequately assess and diagnose the patient.
The College cautioned the ED physician with respect to the delayed diagnosis of cerebral hemorrhage. In particular, the College was critical of the following:
- his failure to obtain or document an adequate history or physical examination as he did not consider the patient's fall to be a significant contributing factor to her presenting condition
- the questionable finding of a normal neurological examination as it differed from the documented assessments of both the pre-hospital and nursing personnel
- his failure to communicate significant information about the patient's head trauma history to the hospitalist during the handover of care
- his illegible documentation
The College also cautioned the hospitalist for not assessing a patient with a history of a recent fall when advised of the patient's worsening neurological symptoms.
Although resource deficiencies were often beyond the control of the physician in the cases analyzed, they nonetheless interfered with the performance of various diagnostic and therapeutic measures. Resource problems were particularly problematic in non-tertiary centres.
The following resource deficiencies were identified:
- medical equipment resource issues (e.g. CT scanner not available on-site or being serviced; end-tidal carbon dioxide (ETCO2) monitor malfunctioned during patient intubation)
- human resource issues (e.g. lack of or unavailability of specialists; no CT scan technician available overnight)
- lack of trauma beds in tertiary care centres
- insufficient land and air emergency transportation services
Unavailable trauma bed
A 73-year-old man was involved in a lateral impact MVC. On arrival to the ED, his vital signs were stable and his Glasgow Coma Score (GCS) was 14. The ED physician examined the patient and numerous investigations were carried out. The patient was diagnosed with multiple fractures, including cervical spine (C-spine), ribs, and extremities, as well as closed head injury, pulmonary contusion, kidney, and bladder injuries. The ED physician attempted to transfer the patient to a trauma centre. However, no beds were available at two tertiary care hospitals, and inclement weather precluded air ambulance transport. Hypotensive episodes responded to IV fluid boluses and blood transfusions. Appropriate surgical specialists assessed the patient and recommended conservative injury management; no immediate surgical interventions were required.
Later that evening the patient was transferred to the ICU in stable condition. In the early morning the patient developed respiratory difficulties and was intubated with improvement. The on-call internist remained in hospital and advised the nursing personnel to contact her of any change in the patient's condition. The nurses notified the internist of hypotensive episodes repeatedly during the night. By telephone she ordered boluses of fluid replacement and blood transfusions, to which the patient responded well, but she did not attend the patient. The patient's condition gradually deteriorated. Despite appropriate treatment, he died. Autopsy concluded the death was due to multiple MVC-related blunt injuries, disseminated intravascular coagulation (DIC), and bilateral pulmonary fat emboli.
The family initiated a College complaint alleging inadequate management of the patient, failure to transfer the patient to a trauma centre, and failure of the internist to attend the patient overnight.
The College was of the opinion that the care provided by all of the physicians was reasonable and appropriate. The College supported the ED physician for making reasonable attempts to transfer the patient to a trauma unit. In addition, the patient appeared stable and, considering the inclement weather, it was prudent not to transfer him. The internist's attendance may not have altered the outcome, but it would have been reassuring. The College believed the patient's underlying conditions (i.e. DIC, persistent blood loss and fat emboli) were not amenable to treatment.
Risk management considerations
The following risk management considerations are based on the expert opinions in the analyzed cases:
- Have a system or process in place to provide quality patient care when the required resources, such as professional care, healthcare equipment, bed, and patient transportation, are not available.
- Review the notes written by other healthcare professionals, including those accompanying the patient, when the patient is transferred from another centre.
- Document clearly, completely, and accurately. Include the patient's symptoms, physical findings, and relevant diagnostic investigation results.
- Write legibly.
- During the handover of care, communicate the history and mechanism of injury, pertinent clinical information, and investigation results. Emphasize the need for follow-up, if indicated.
- Provide and document clear discharge instructions to the patient and family. Check that your instructions have been understood.
- For the purpose of this article, multi-system trauma is defined as trauma involving two or more body systems (excluding superficial injuries), and life-threatening trauma is defined as a single or multiple-system injury resulting in major patient disability or death.