Citation

Butler MJ, Arneil C, Whitelaw AS, Thomson K, Gordon MWG, Thorburn J, Shiels D, Lowe DJ. BMC Emerg. Med. 2024; 24(1): e136.

Copyright

(Copyright © 2024, Holtzbrinck Springer Nature Publishing Group - BMC)

DOI

10.1186/s12873-024-01022-w

PMID

39075337

PMCID

PMC11288075

Abstract

BACKGROUND: The current UK standard for major trauma patients is to record notes in a paper trauma booklet. Through an innovative collaboration between a major trauma centre and a digital transformation industry partner, a TraumaApp was developed. Electronic notes have been shown to have fewer errors, granular data collection and enable time stamped contemporaneous record keeping. Implementation of digital clinical records presents a challenge within the context of trauma multidisciplinary trauma resuscitation. Data can be easily accessible and shared for quality improvement, audit and research purposes. This study compared paper and electronic notes for completeness and for acceptability data following the implementation of the TraumaApp.

METHODS: Trauma team members who performed scribe function attended training for the newly launched TraumaApp. Two staff members acted as scribe, using either the paper trauma booklet or TraumaApp, and attended major trauma calls. A framework for comparison of paper and electronic notes was created and used for a retrospective review of major trauma patients' notes. Statistical analysis was performed using a two-tailed t-test. Staff using the TraumaApp completed a System Usability Score questionnaire.

RESULTS: There was a total of 37 data points for collection per case. The mean numbers collected were paper notes 24.1 of 37 (65.1%) and electronic notes, 25.7 of 37 (69.5%). There was no statistical significance between the completeness of paper and electronic notes. The mean System Usability Score was 68.4.

DISCUSSION: Recording accurate patient information during a major trauma call can be challenging and the role of the scribe to accurately record events is critical for immediate and future care. There was no statistically significant difference in completeness of paper and electronic notes, however the mean System Usability Score was 68.4, which is greater than the internationally validated standard of acceptable usability.

CONCLUSION: It is feasible to introduce digital data collection tools enabling accurate record keeping during trauma resuscitation and improve information sharing between clinicians.

Language: en

Keywords

Humans; Trauma; Retrospective Studies; United Kingdom; Documentation; Trauma Centers; Mobile Applications; *Electronic Health Records; *Wounds and Injuries/therapy; Electronic clinical decision making; Usability