4.clinical audit 2024 Tool Trauma April 2016.docx

clinical audit 2024

1. Audit Tool: Trauma
Facility name Deder General Hospital
Department/unit Emergency and Critical Care department
Audit Topic Trauma management in the ED
Aim To improve quality of clinical care provided to trauma patients
Objectives To ensure trauma patients presenting to the emergency are appropriately evaluated
To ensure trauma patients presenting to the emergency are appropriately investigated
To ensure trauma patients presenting to the emergency are appropriately treated
To ensure trauma patients presenting to the emergency are appropriately disposed
Period of Audit April 2016E.C
Inclusion criteria All trauma patients aged 14 and above, treated in the emergency with-in the study period
Exclusion criteria (where applicable) Patients who arrived 24 hours after sustaining trauma
Instructions For criteria- If completed give ‘Yes’ if not give ‘No’ ,give NA if the criterion does not apply to the individual patient
For sub-elements (ones in blue)- if completed give ‘1’ if not give ‘0’ , give NA if the sub-element does not apply to the
individual patient
No Standards/criteria Target
Data Source
and verifica-
tion
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9
Actual
perfor-
mance
Perfor-
mance
against
target
Remark
1 IDENTIFICATION INFORMATION
IS RECORDED FOR A PATIENT PRE-
SENTING WITH TRAUMA
100% 83
%
100
%
100
%
83
%
83
%
83
%
100
%
83
%
100
%
83
%
100
%
100
%
83
%
100
%
83
%
84%

1.1Name
Patient’s ED
Admission
note
YesYesYesYesYesYesYesYesYesYesYesYesYesYesYes
1.2Age YesYesYesNoYesYesYesYesYesYesYesYesYesYesYes
1.3Sex NoYesYesYesYesNoYesYesYesYesYesYesYesYesYes
1.4Date of visit YesYesYesYesYesYesYesYesYesYesYesYesYesYesYes
1.5Time of visit YesYesYesYesNoYesYesYesYesYesYesYesYesYesYes
1.6MRN YesYesYesYesYesYesYesNoYesNoYesYesNoYesNo
2 APPROPRIATE EVALUATION
AND MANAGEMENT FOR
ACUTE LIFE THREATENING
INJURIES IS DONE FOR A
PATIENT PRESENTING WITH
TRAUMA USING STANDARD
100% 94
%
100
%
100
%
83
%
83
%
83
%
100
%
83
%
100
%
83
%
100
%
100
%
83
%
100
%
83
%
78%
2
4
2

2. TRAUMA CARE PRINCIPLES
2.1Evaluation of airway patency is done
(airway labeled as clear/patent or state-
ments such as presence of secretion,
presence of foreign body or injury to
the face is written)
Triangulate
Patient ED
Admission
Note, Order
Sheet, Pro-
cedure Note,
Medication
Sheet and
Vital Sign
Sheet
YesYesYesYesYesYesYesYesYesYesYesYesYesYesYes
2.2If patient has secretion secretions are
suctioned out
NANANANANANANANANANANANANANANA
2.3If foreign body is present it is removed NANANANANANANANANANANANANANANA
2.4Airway management is done (Oral air-
way or insertion or supraglottic device
placement or endotracheal intubation
or surgical airway)
NANANANANANANANANANANANANANANA
2.5Evaluation of cervical stability is done
for patients with GCS score of 15.
YesYesYesYesYesYesYesYesYesYesYesYesYesYesYes
2.6Cervical collar is secured for cervical
injury suspected patients (Use NEXUS
criteria)
NANANANANANANANANANANANANANANA
2.7Appropriate breathing evaluation is
made
YesYesYesYesYesYesYesYesYesYesYesYesYesYesYes
Oxygen saturated measured 111111111111111
Respiratory rate counted 110111111111111
Respiratory movement symmetry
assessed
111111111111111
Chest is auscultated 110111111111111
2.8Oxygen is provided using nasal prong
or face mask
NANANANANANANANANANANANANANANA
2.9Ventilation is provided using bag valve
mask for patients with low GCS or
apneic patients until definitive airway
is secured
NANANANANANANANANANANANANANANA
2.11Ventilation is provided using mechan-
ical ventilator for patients who have
indication for intubation
NANANANANANANANANANANANANANANA
2.12Needle thoracostomy is done for pa-
tients with suspected tension pneumo-
thorax
NANANANANANANANANANANANANANANA

3. 2.13Chest tube is inserted for patient with
open/closed pneumothorax and/or
hemothorax and/or flail chest
NANANANANANANANANANANANANANANA
2.14Evaluation for active external
bleeding is done
YesYesYesYesYesYesYesYesNAYesYesYesYesNAYes
2.15Active bleeding is stopped if present
Triangulate
Patient ED
Admission
Note, Order
Sheet, Pro-
cedure Note,
Medication
Sheet and
Vital Sign
Sheet
NANANANANAYesNANANANAYesYesYesNAYes
2.16If tourniquet is used to stop bleeding,
tourniquet time is clearly recorded on
chart
NANANANANAYesNANANANANANANANAYes
2.17Blood pressure is measured
YesYesYesYesYesYesYesYesYesYesYesNANANANA
2.18Pulse rate is measured
YesYesYesYesYesYesYesYesNANAYesYesYesYesYes
2.19IV line is secured: Peripheral percuta-
neous
YesNANANAYesNANANAYesYesNANANoNANo
2.21Intravenous access/ Intraosseous ac-
cess/ Venous cut down/ Central
venous access is established
NANANANANANANANANANANANANANANA
2.22NS/RL is administered and/or blood
transfused if patient is hypovolemic
YesNANANAYesNANANANANAYesNANANANA
2.23Pelvic stability is checked
YesYesYesYesYesYesYesYesYesYesYesYesYesYesYes
2.24Pelvic stabilization is done if unstable
NANANANANANANANANANANANANANANA
2.25GCS is assessed
YesYesYesYesYesYesYesYesYesNoYesYesNAYesYes
2.26Pupillary size and reaction are checked
YesYesYesYesYesYesYesYesYesYesYesYesYesYesYes
2.27Motor preference is checked
YesYesYesYesYesYesYesYesYesYesYesYesYesYesYes
2.28RBS is checked
NoYesYesNoNoNoNoYesYesNoNANoYesNoNo
2.29Dextrose is given if patient is hypogly-
cemic
NANoYesNAYesYesNANANANANANANANANA
2.31Log-roll is done
YesYesYesYesYesYesYesYesYesYesYesYesYesYesYes
2.32Patient is evaluated for presence
of wounds
YesYesYesYesYesYesYesYesYesYesYesYesYesYesYes
2.33Fractures are immobilized if present
NANANANAYesNANANANANANANANANANA
2.34Digital rectal examination is done
NANANANANANANANANANANANANANANA
2.35Spinal stability is checked
YesYesYesYesYesYesYesYesYesYesNANANANANA
2
4
3

4. 2.36Bed side ultrasound is done (FAST/
eFAST)
NANoNANoNoNoNoNoNoNANANANANANA
3 DETAILED HISTORY TAKEN AND
PHYSICAL EXAMINATION PER-
FORMED FOR A PATIENT PRE-
SENTING WITH TRAUMA
100% 100
%
100
%
88
%
100
%
100
%
100
%
100
%
100
%
100
%
88
%
100
%
100
%
100
%
100
%
100
%
98%

3.1Signs and symptoms related to
the trauma are assessed
Patient’s ED
Admission
Note
YesYesYesYesYesYesYesYesYesYesYesYesYesYesYes
3.2Presence of drug or medication allergy
is assessed
YesYesYesYesYesYesYesYesYesYesYesYesYesYesYes
3.3History of chronic medication usage is
assessed
YesYesYesYesYesYesYesYesYesYesYesYesYesYesYes
3.4Past medical and surgical history is
taken
Patient’s ED
Admission
Note
YesYesYesYesYesYesYesYesYesYesYesYesYesYesYes
3.5Time of last oral intake is identified YesYesYesNoYesYesYesYesYesYesNoYesYesYesYes
3.6Events: time of incident, accounts of
the event, injuries to other people are
inquired
YesYesYesYesYesYesYesYesYesYesYesYesYesYesYes
3.7Vital signs are measured
Patient’s Vital
Sign Sheet
YesYesYesYesYesYesYesYesYesYesYesYesYesYesYes
BP
11111111111NANA11
PR
111111111111111
RR
111111111111111
Oxygen saturation(SPO2)
111111111111111
Temperature
011000110101011
Pain score
101111111111010
3.8Head to toe physical examination
is done (HEENT, R.S, CVS,
ABD,MSK, GUS, CNS)
Patient’s ED
Admission
Note
YesYesYesYesYesYesYesYesYesYesYesYesYesYesYes
4 RELEVANT INVESTIGATION ARE
DONE FOR A PATIENT
PRESENT- ING WITH TRAUMA
80% 100
%
0%100
%
0%100
%
0%100
%
50
%
50
%
50
%
0%0%0%5067
%
34
4.1Imaging of the affected body part is
done Triangulate
YesNANANoYesNoNAYesNoYesNoNoNoNoYes
2
4
4

5. the history,
P/E
findings
with diag-
nosis on the
patient’s ED
Admission
Note with in-
vestigations
papers
4.2Trauma series is done: C-spine, Chest,
Thoracolumbar & pelvic -XR for
polytrauma patient
NANANANANANANANANANANANANANANA
4.3CBC, Blood group & Rh, Cross-match,
urine HCG (for reproductive age
female patient) are determined
NANoYesNAYesNoYesNoYesNoNoNoNoYesYes
4.4RFT and serum electrolytes are done
for severe TBI, crush injury and shock
patients
NANANANANANANANANANANANANoNoNo
5 APPROPRIATE DIAGNOSIS IS
MADE FOR A PATIENT PRESENT-
ING WITH TRAUMA
100% 100
%
100
%
100
%
100
%
100
%
100
%
100
%
100
%
100
%
100
%
100
%
100
%
100
%
100
%
100
%
100%
5.1All injuries are appropriately diagnosed
and written including complications
from the injury/injuries
Triangulate
the history
findings with
the diagno-
sis on ED
Admission
Note
YesYesYesYesYesYesYesYesYesYesYesYesYesYesYes
5.2Type of injury is recorded (RTA, falling
down accident, gun shot etc.) YesYesYesYesYesYesYesYesYesYesYesYesYesYesYes
6 APPROPRIATE TREATEMENT IS
PROVIDED FOR A PATIENT
PRE- SENTING WITH
TRAUMA
100% 100%
6.1Wound cleaning, suturing, and dressing
are done for patient with wounds
Triangulate
the history,
P/E
findings on
ED
admission
note with the
order on
the Order
Sheet
YesYesYesYesYesYesYesYesNAYesYesYesYesYesYes
6.2Supportive management is started YesYesYesYesYesYesYesYesYesYesYesYesYesYesYes
Urinary catheter inserted for immobile
and GCS < 14 patients
NANANANANANANANANANANANANANANA
GI prophylaxis (polytrauma patients
and severe TBI patients, patients
with NG-tube in-situ)
NANANANANANANANANANANANANANANA
Pain management is provided 111111111111111
2
4
5

6. 6.3Consultation to concerned depart-
ments is made within 1 hr
Triangulate
the time of
patients first
evaluation
with the time
the con-
sultation is
made on
the
consultation
Paper
NANANANANANANANANANANANANANANA
7 APPROPRIATE PATIENT DISPO-
SITION IS DONE FOR A PATIENT
PRESENTING WITH TRAUMA
100% 100
%
100
%
100
%
100
%
100
%
100
%
100
%
100
%
0%0%100
%
100
%
100
%
100
%
100
%
78% 88%
7.1Adequate discharge care is provided for
patient who is discharged to home care
Discharge
Note
YesYesYesYesYesYesYesYesNoNoYesYesYesYesYes
Advise is provided on danger signs 111011110001111
Appropriate wound care referrals is
given
110111010000111
Pain management prescription is
provided
1NA0001010000011
Follow up appointment is given 1NA0000000000000
2
4
6

7. 7.2For patient who is admitted either
to ward, OR ICU, admission is
provided with-in 24 hours.
Triangulate the
time of patient ar-
rival and the
diagnosis on ED
admis- sion Note
with the time of
admission on ED
trans- fer note/
ED order sheet
NANANANANANANANANANANAYesNANANA
7.3For patient who can not be treated
at the facility, appropriate referral is
made as per national standard
Triangulate the
progress note with
re- ferral Paper
NANANANANANANANANANANANANANANA
8 IDENTIFICATION OF CARE PRO-
VIDER IS DOCUMENTED FOR
A PATIENT PRESENTING WITH
TRAUMA
100% 100
%
100
%
100
%
100
%
100
%
100
%
100
%
100
%
100
%
100
%
100
%
100
%
100
%
100
% 100%
8.1Name and signature of the
physician is clearly documented on all
admission history and P/E sheets
ED admis-
sion Note
YesYesYesYesYesYesYesYesYesYesYesYesYesYesYes
8.2Name and Signature of the
physician is clearly documented on
all progress notes
ED progress NoteYesYesYesYesYesYesYesYesYesYesYesYesYesYesYes
8.3Name and signature of the physician is
clearly documented on all order sheets
ED order
Sheet
YesYesYesYesYesYesYesYesYesYesYesYesYesYesYes
8.4Name and signature of the nurse
is clearly documented on all
medication sheets
ED medica-
tion Sheet
YesYesYesYesYesYesYesYesYesYesYesYesYesYesYes
9 A PATIENT PRESENTING WITH
TRAUMA DIED WITHIN 48
HOURS OF HOSPITAL ARRIVAL
TO THE HOSPITAL (CAN BE
WITH IN OR OUT SIDE THE
EMERGENCY DE- PARTMENT)
4%
NANANANANANANANANANANANANANANA
Total standards met per chart
777846575547756
78%
Percentage
77
%
77
%
77
%
88
%
50
%
75
%
63
%
77
%
63
%
63
%
50
%
77
%
77
%
63
%
75
%