A Case for a Data Collection Worksheet, and a Guide for Design Deborah Hutton, RHIT, CSTR & Michelle Pomphrey, MLT, RN, CSTR Introduction Each trauma program in the nation relies on accurate and timely data. This involves each aspect of data collection as well as data entry. In most instances the larger the program the larger the headache this can become. Many feel that being in a rural area, smaller hospital, or minimum volume per year lessons the impact of timeliness. However, even these institutions are required to submit data in a timely manner either to the program director, region or state trauma registry. Therefore data collection and data entry need a renewed focus. Concurrent data collection typically utilizes a data collection worksheet. These worksheets need not be complicated. The major benefit of a well organized worksheet is its ability to prompt the abstractor for all relevant data point during chart review. This completeness decreases the chance of missing a data element, and thus repeat reviews or trips to the medical record. Additional benefits include, increased time management, efficient data entry, and consistency. Smaller hospitals with low volumes such as 12 to 100 patients per year may utilize direct data entry and view worksheets as a “waste of time.” On the opposite side of this, large programs who utilize multiple informational downloads may also opt to do direct data entry. Each facility differs in needs and resources; therefore the decision for utilizing an organized data collection worksheet must be made individually. A Case for Utilizing a Data Collection Worksheet As stated the major benefit of a well organized worksheet is its ability to prompt the abstractor for all relevant data points during initial chart review. Level I and II facilities as well as hospital systems which have multiple facilities transferring patients would greatly benefit from the worksheet. The worksheet will prompt for each data element required as you view the multiple data sources. Multiple data sources such as first responder, prehospital provider, transfer facility, interfacility vehicle, emergency department, laboratory, radiology, operating room and so on, increases the likelihood of missing a specific data element if the chart is abstracted as direct data entry. In theory direct data entry, the abstractor / data entry person would review the chart and fill in the data screens element by element completely with a single review, thus the “draw” for illusion of time efficiency. The major drawback to this method is the data screen elements do not flow the same way the patient’s medical record does. To perform direct data entry the trauma registry personnel must either A) review the chart front to back and manipulate the software jumping from screen to screen filling in data, (or try to remember an element and enter when that screen is come to) or B) go screen data element by data element and continually jump around in the chart. In both of these methods the likelihood of missing a data element increases, as well as time efficiency decreases.
A good analogy of direct data entry would be a trip to the grocery store in which no grocery list was made. The shopper could either A) try and remember each item from memory and run around the store gathering these items one by one, or B) start walking up and down each isle looking at every item and trying to remember which ones were needed. Neither of these methods are time efficient when you need 150 to 300 items; the same is true for trauma registries where multiple informational downloads are not utilized. An organized data collection worksheet can prompt the abstractor for each element that is needed to complete the trauma patient records, and do so in a fashion which maximizes time efficiency. Method A well designed worksheet should meet the needs of everyone involved in data collection, or data entry. It should ensure accuracy and completeness, while maximizing efficiency. There are several key elements for accomplishing the task. Key element 1) organize the worksheet to match the screens of your trauma registry software and not the medical record. The key benefits are: maximum data entry efficiency and minimal data entry errors. This functions under the old typing guideline of needing to master the skill of typing a letter from a draft and not needing to view the screen. If the elements flow exactly as the screens flow, the data entry personnel could, in theory, complete data entry without looking at the screen. The data abstractor can flip through the chart or even the worksheet to record a data element answer much than the data entry personnel can flip thru screens to enter the same information. Key element 2) the worksheet can be divided into sections to match the sections of the database. This is a simple process each trauma software system is divided by demographics, transport agencies, transferring facilities, emergency departments, procedures, injuries, discharge information, and complications / quality improvement. Therefore the worksheet should also be sub-divided. Back to the grocery store analogy, your grocery list would have a special place for frozen foods, fresh produce, dairy, breads, meats, and cleaning supplies. This speeds up the shopping experience and ensures that at the check out line it is not discovered an item is missing and the shopper must go back to that department to retrieve it. The same is true with the trauma registry; this method decreases the percentage of missed data elements which must be re-review at patient discharge. Key element 3) the worksheet should maximize efficiency by maximizing pick lists. Simply put, each trauma registry software system requires the abstractor to capture the Ecode of the event. This field is pick list driven for each software system based on the International Classification of Disease 9th Revision Clinical Modification (ICD-9-CM) system. Therefore to maximize efficiency simply add a modified version of this pick list to the worksheet. The modification would simply be the most common E-codes, such as Motor Vehicle, Falls, Assaults, etc, and less common ones could be hand written in for coding during the data entry phase. This allows the abstractor to simply circle an answer,
and the data entry personnel to then enter the corresponding information directly into the system without having to access the pick list, find the code and then double click to enter it into the system. In this system, using the grocery store analogy would be the preprinted grocery list that which list common items such as bread, milk, coffee, toilet paper, tea, etc and the item is simple circled or checked if needed. Key element 4) the worksheet should cover all needed data elements. This appears to be the same as key element #1, however this has a deeper meaning. Each data element collected requires approximately 10 minutes of time. This time includes; someone having to document it in the chart initially, the abstractor to locate, record, enter, and potentially validate it at a later date. Therefore ensuring that all relevant data is collected as well as eliminating irrelevant data is a necessary process which should occur every six months. All key elements must be included to satisfy all internal quality improvement measures, as well as all external requirements such as but not limited to: state elements, regional or national database items. If on review there are data elements that are needed and the vendor software system does not currently display them, schedule a time to discuss with the vendor ability to custom design elements. Specific individuals who may request specific data elements related to information they need for their jobs could be, but certainly not limited to: specific physician, physician services, injury prevention coordinator, residents, unit managers, nurses, and prehospital agencies. As you consider adding these data elements as requested, be aware that even if Dr. Jones request capturing how many of his patients play tennis, does not mean that information will be documented in the charts. Therefore as additional elements are decided upon, guidelines and restrictions may need to be established. For example, with Dr. Jones, the guideline could be the information will be captured and documented in the trauma registry as long as the information is documented on the history and physical. Therefore if Dr. Jones really “needs” this information he must ensure that his residents ask the questions and document the answers. The trauma coordinator or trauma program manager and the trauma registrar should have the final word on elements to be included on the worksheet. The primary function of this worksheet is to ensure all data elements are collected and thus entered into the trauma registry in an accurate and timely fashion. Therefore for maximum efficiency the worksheet should include all data elements, and mirror as much as possible the data screens, data element by data element. The latter is fundamental for maximal efficiency in data entry. If a case manager or care coordinator collects additional information such as but not limited to, delay day causes, complications, guideline adherence, etc this information would be better suited as a separate worksheet design. The rationale for this is simple; this separate worksheet would be kept by the manager or coordinator, updated daily, and then submitted to the trauma registry office after patient discharge for data entry. The worksheets would be designed with the same functional guidelines as the regular worksheet in format, as well as acceptable data element answer options. Specifically, the data element answer options would be pick list driven answers verses narrative driven for reproducibility.
Discussion In utilizing an organized trauma worksheet, the facility benefits from complete data abstraction on one form, utilizing pick list to ensure accuracy, as well as the maximum benefit of time efficiency of data entry. However the benefits of worksheets stretch beyond these to incorporate, narrative comments from abstractor to data entry personnel, as well as a method for prompting physicians for clarification of injuries, to tracing issue for department education. In utilizing a worksheet during the patient’s hospital stay, this is a continuation of events, day one the pre-hospital agency run sheet may be missing but when the chart is reviewed on day three for updates, the abstractor can see at a glance the areas of missing data, and instantly know items to again look for. Thus this method acts as a reminder or prompts for the abstractor. This process can also act as a fast method for tracing data integrity issue which may identify educational needs. For example, if your facility is having issues with emergency department documentation of temperatures, the question is, are they being done and documented somewhere else, or are then simply not being done. On investigation it is discovered that temperatures are being done and documented on a separate sheet which is typically not reviewed by the trauma registrar. In this example several key items have been discovered. First recording of temperatures is not an issue; the issue is locating the information. By investigating, the problem was identified, discussed, education occurred and, with a small revision, the trauma flow sheet is now the primary source for this information. The nurse does not need to document in two locations, and the trauma registrar saves time by looking in only one location for the needed information. This may seem like a small thing but having as much data in one place, defined to be on a certain form speeds up the data collection process for the trauma registry. In a busy peak time, several hours can be consumed over a week’s time searching for information scattered between different forms. Thus by utilizing this method upon patient discharge all data available has been collected, recorded in one place, in a format mirror image to the trauma registry software system. Thus data entry is much faster and the data should be more accurate and complete, lending to a more valid trauma registry. However do not be mislead, data validation is still a necessary process. In reviewing the same situation but performing data entry after the initial review, all updates, or re-review for missing data can be recorded in a different color ink to facilitate quick data entry is also possible. This is the preferred methodology over data entry once the patient is discharged. However instead of daily data entry of updates, updates can be entered at discharge while the initial data (80% complete data) can be entered initially. Updates are typically, missing data, missed injuries, additional procedures, or complications / quality issues.
Conclusion A well organized trauma registry worksheet may take an initial investment of time and energy to design, however this is an investment in efficiency. Each worksheet will look different depending on institutional needs / demands. However the worksheet is designed to make life easier, but streamlining data abstraction and data entry. A trauma registry is an essential element for a trauma program, and as such it must be valid and complete. The trauma registry is a real asset to all elements of trauma, and by maximizing efficiency we maximize potential and growth.